=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407284094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KYLE W. KENNEDY, DO, FACOEP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2013
-----------------------------------------------------
Last Update Date | 10/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 W 32ND ST
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-347-6670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1117 N LIBERTY ST
-----------------------------------------------------
City | WEBB CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64870-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. KYLE KENNEDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-499-2692
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 2004009698
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------