Healthcare Provider Details

I. General information

NPI: 1922060599
Provider Name (Legal Business Name): SCOTT A KENNEDY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N FRANKLIN ST
TITUSVILLE PA
16354-1761
US

IV. Provider business mailing address

1073 S MAIN ST
MEADVILLE PA
16335-3129
US

V. Phone/Fax

Practice location:
  • Phone: 814-827-7931
  • Fax: 814-827-0746
Mailing address:
  • Phone: 814-333-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOEG000659
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOEG000659
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOEG000659
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: