MEDICARE: DR. ROBERT MICHAEL KENNEDY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	M4241	ID

General Provider Information

NPI Number	:	1043219694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT MICHAEL KENNEDY M.D.

Provider Business Mailing Address
First Line	:	777 HOSPITAL WAY
Second Line	:	G15
City	:	POCATELLO
State	:	ID
Zip	:	83201-5175
Country	:	US
Telephone Number	:	208-239-2722
Fax Number	:	208-239-3759

Provider Business Practice Location Address
First Line	:	777 HOSPITAL WAY
Second Line	:	G15
City	:	POCATELLO
State	:	ID
Zip	:	83201-5175
Country	:	US
Telephone Number	:	208-239-2722
Fax Number	:	208-239-3759

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2005
Last Update Date	:	01/31/2013

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