Provider Demographics
NPI:1669582581
Name:KENNEDY, REBECCA J (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 S MILWAUKEE AVE
Mailing Address - Street 2:#181
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-816-1228
Mailing Address - Fax:847-816-1262
Practice Address - Street 1:755 S MILWAUKEE AVE
Practice Address - Street 2:#181
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-816-1228
Practice Address - Fax:847-816-1262
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E56121Medicare UPIN