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NPI Code Detail

MEDICARE: KENNEDY TOOLE PA-C

MEDICARE: KENNEDY TOOLE PA-C
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
1363AS0400XSurgical Physician Assistant1194448SC

General Provider Information

NPI Number : 1619693132
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNEDY TOOLE PA-C
Provider Business Mailing Address
First Line : 922 COMET CREEK LN
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29486-8045
Country : US
Telephone Number : 803-474-2043
Fax Number :
Provider Business Practice Location Address
First Line : 3045 SAINT MATTHEWS RD
Second Line :
City : ORANGEBURG
State : SC
Zip : 29118-1443
Country : US
Telephone Number : 803-747-7242
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2022
Last Update Date : 10/17/2022

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Directions to “ KENNEDY TOOLE PA-C” Practice Location

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