Healthcare Provider Details

I. General information

NPI: 1043088750
Provider Name (Legal Business Name): IAN MICHAEL KENNEDY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/13/2023
Certification Date: 12/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OHIO ST
MEDINA NY
14103-1063
US

IV. Provider business mailing address

6141 VERSAILLES RD
LAKE VIEW NY
14085-9625
US

V. Phone/Fax

Practice location:
  • Phone: 585-798-2000
  • Fax:
Mailing address:
  • Phone: 716-400-4725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number042563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: