Provider Demographics
NPI:1700885498
Name:KENNEDY, STEPHEN D (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 W BRICK RD STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-8420
Mailing Address - Country:US
Mailing Address - Phone:574-247-1911
Mailing Address - Fax:574-247-1912
Practice Address - Street 1:5838 W BRICK RD STE 106
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628
Practice Address - Country:US
Practice Address - Phone:574-247-1911
Practice Address - Fax:574-247-1912
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013733207Q00000X
IN02001650A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200081840AMedicaid
IN253470AMedicare PIN
IN200081840AMedicaid