MEDICARE: DR. COLLEEN M KENNEDY D.O.

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0N22720	OTHER	MI	MEDICARE TYPE UNSPECIFIED

General Provider Information

NPI Number	:	1538140744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLEEN M KENNEDY D.O.

Provider Business Mailing Address
First Line	:	75 BARCLAY CIRCLE
Second Line	:	SUITE 225
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307
Country	:	US
Telephone Number	:	248-299-1892
Fax Number	:	248-299-2396

Provider Business Practice Location Address
First Line	:	75 BARCLAY CIR
Second Line	:	SUITE 225
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5820
Country	:	US
Telephone Number	:	248-299-1892
Fax Number	:	248-299-2396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	02/24/2011

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