=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225472392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENEDY ANDON FORYOUNG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2013
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 877 JEFFERSON AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-448-4263
-----------------------------------------------------
Fax | 901-448-1248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3201 JERMANTOWN RD STE 550
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-2885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-667-8600
-----------------------------------------------------
Fax | 703-667-8601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | D87397
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 69972
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | U4683
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | D87397
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------