Healthcare Provider Details

I. General information

NPI: 1932246170
Provider Name (Legal Business Name): MARCUS PETER KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST MAIL SLOT 555
LITTLE ROCK AR
72205-7199
US

IV. Provider business mailing address

4301 W MARKHAM ST MAIL SLOT 555
LITTLE ROCK AR
72205-7199
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-5525
  • Fax: 501-686-7893
Mailing address:
  • Phone: 501-686-5525
  • Fax: 501-686-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberE-5260
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: