MEDICARE: DR. JAMES GRAY 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	207Q00000X	Family Medicine Physician	20996	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20996	OTHER	CO	LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063410603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES GRAY KENNEDY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1312
Second Line	:
City	:	WINTER PARK
State	:	CO
Zip	:	80482-1312
Country	:	US
Telephone Number	:	970-722-0300
Fax Number	:	970-722-1032

Provider Business Practice Location Address
First Line	:	78878 US HIGHWAY 40
Second Line	:
City	:	WINTER PARK
State	:	CO
Zip	:	80482-1312
Country	:	US
Telephone Number	:	970-722-0300
Fax Number	:	970-722-1032

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

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	12/01/2011

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