Healthcare Provider Details

I. General information

NPI: 1164816542
Provider Name (Legal Business Name): GREGORY KENNEDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204
US

IV. Provider business mailing address

1623 SAINT PAUL ST UNIT 201
DENVER CO
80206-1666
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-2716
  • Fax:
Mailing address:
  • Phone: 314-560-2292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0060165
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: