Healthcare Provider Details

I. General information

NPI: 1629519574
Provider Name (Legal Business Name): RICHARD KENNEDY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2017
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 HANOVER DR STE 104
GREENBELT MD
20770-2250
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR STE 650
GREENBELT MD
20770-3560
US

V. Phone/Fax

Practice location:
  • Phone: 301-486-4690
  • Fax:
Mailing address:
  • Phone: 301-982-2000
  • Fax: 301-982-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006406
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: