Healthcare Provider Details

I. General information

NPI: 1255438214
Provider Name (Legal Business Name): GENE SCOTT KENNEDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HERON WALK
SAINT SIMONS ISLAND GA
31522-2585
US

IV. Provider business mailing address

116 ASBURY ST
SAINT SIMONS ISLAND GA
31522-2209
US

V. Phone/Fax

Practice location:
  • Phone: 912-634-2651
  • Fax: 912-634-2653
Mailing address:
  • Phone: 912-634-2651
  • Fax: 912-634-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number050645
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: