Healthcare Provider Details

I. General information

NPI: 1609817618
Provider Name (Legal Business Name): PHILLIP S KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 D J DEWEY GRAY CIRCLE
AUGUSTA GA
30909
US

IV. Provider business mailing address

PO BOX 2510
EVANS GA
30809-2510
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-7380
  • Fax: 706-868-7223
Mailing address:
  • Phone: 706-922-8251
  • Fax: 706-922-6695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number043985
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: