Healthcare Provider Details

I. General information

NPI: 1942681150
Provider Name (Legal Business Name): SEAN KENNEDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2972 INDIAN TRAIL RD STE A
AURORA IL
60502-9408
US

IV. Provider business mailing address

2972 INDIAN TRAIL RD STE A
AURORA IL
60502-9408
US

V. Phone/Fax

Practice location:
  • Phone: 630-499-0812
  • Fax: 630-499-0823
Mailing address:
  • Phone: 630-499-0812
  • Fax: 630-499-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125067575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: