MEDICARE: COLLEEN M KENNEDY DO PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101012334	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0P10800	OTHER	MI	GROUP/ORGANIZATION

General Provider Information

NPI Number	:	1497941850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEEN M KENNEDY DO PC

Provider Business Mailing Address
First Line	:	305 BARCLAY CIR
Second Line	:	SUITE 1000
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-4572
Country	:	US
Telephone Number	:	248-299-1892
Fax Number	:	248-853-2809

Provider Business Practice Location Address
First Line	:	305 BARCLAY CIR
Second Line	:	SUITE 1000
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-4572
Country	:	US
Telephone Number	:	248-299-1892
Fax Number	:	248-853-2809

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. COLLEEN M KENNEDY
Credential	:	D.O.
Telephone Number	:	248-299-1892

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	09/19/2007

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