MEDICARE: LISA A KENNEDY O.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	152W00000X	Optometrist	S-987-TA-572	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S-987-TA-572	OTHER	AL	AL BOARD OF OPTOMETRY

General Provider Information

NPI Number	:	1407822265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A KENNEDY O.D.

Provider Business Mailing Address
First Line	:	PO BOX 43366
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35243-0366
Country	:	US
Telephone Number	:	205-995-2020
Fax Number	:	205-991-9654

Provider Business Practice Location Address
First Line	:	4515 SOUTHLAKE PKWY
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35244-3317
Country	:	US
Telephone Number	:	205-987-2020
Fax Number	:	205-988-0588

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	03/07/2023

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Directions to “ LISA A KENNEDY O.D.” Practice Location

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