MEDICARE: MR. MICHAEL ARTHUR KENNEDY PA-C

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	363AM0700X	Medical Physician Assistant	PA04828	TX

General Provider Information

NPI Number	:	1245391473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ARTHUR KENNEDY PA-C

Provider Business Mailing Address
First Line	:	1038 ADDISON AVE
Second Line	:
City	:	POTTSBORO
State	:	TX
Zip	:	75076-7077
Country	:	US
Telephone Number	:	903-786-8916
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 E HWY 120
Second Line	:	STE. 104
City	:	POTTSBORO
State	:	TX
Zip	:	75076-3008
Country	:	US
Telephone Number	:	903-786-3911
Fax Number	:

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	02/19/2009

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