Healthcare Provider Details

I. General information

NPI: 1700957123
Provider Name (Legal Business Name): STEPHEN D KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 W 2ND ST STE 100
PERU IN
46970-1385
US

IV. Provider business mailing address

751 W 2ND ST STE 100
PERU IN
46970-1385
US

V. Phone/Fax

Practice location:
  • Phone: 765-919-4378
  • Fax: 765-919-4672
Mailing address:
  • Phone: 765-919-4378
  • Fax: 765-919-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01044433
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: