Healthcare Provider Details

I. General information

NPI: 1669543047
Provider Name (Legal Business Name): GARY J KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MMC - DEPT. OF PSYCHIATRY 111 E. 210TH STREET
BRONX NY
10467
US

IV. Provider business mailing address

446 E 86TH ST APT. 11C
NEW YORK NY
10028-6466
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4236
  • Fax:
Mailing address:
  • Phone: 718-920-4236
  • Fax: 718-920-6538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number140501
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: