Healthcare Provider Details

I. General information

NPI: 1609450402
Provider Name (Legal Business Name): MARK EUGENE KENNEDY II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6847 N CHESTNUT ST
RAVENNA OH
44266-3929
US

IV. Provider business mailing address

6847 N CHESTNUT ST
RAVENNA OH
44266-3929
US

V. Phone/Fax

Practice location:
  • Phone: 330-297-0811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35.153167
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: