MEDICARE: EVAN KENNEDY PT

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	225100000X	Physical Therapist	011060	CT

General Provider Information

NPI Number	:	1366989279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN KENNEDY PT

Provider Business Mailing Address
First Line	:	510 COTTAGE GROVE RD
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3165
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 COTTAGE GROVE RD
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3165
Country	:	US
Telephone Number	:	860-769-6690
Fax Number	:

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

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	01/30/2017

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