Healthcare Provider Details

I. General information

NPI: 1114115045
Provider Name (Legal Business Name): STEPHEN KENNEDY DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 LINCOLN WAY W SUITE O
OSCEOLA IN
46561-2062
US

IV. Provider business mailing address

1415 LINCOLN WAY W SUITE O
OSCEOLA IN
46561-2062
US

V. Phone/Fax

Practice location:
  • Phone: 574-674-6499
  • Fax: 574-674-6490
Mailing address:
  • Phone: 574-674-6499
  • Fax: 574-674-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001650A
License Number StateIN

VIII. Authorized Official

Name: DR. STEPHEN D KENNEDY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 574-255-4733