MEDICARE: STEPHEN KENNEDY, MD, INC.

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	2085R0202X	Diagnostic Radiology Physician	A 86061	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1689668279	OTHER		MEDICARE NPI - INDIVIDUAL FOR DR. STEPHEN KENNEDY

General Provider Information

NPI Number	:	1629188941
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHEN KENNEDY, MD, INC.

Provider Business Mailing Address
First Line	:	9300 W STOCKTON BLVD
Second Line	:	SUITE # 104
City	:	ELK GROVE
State	:	CA
Zip	:	95758-8070
Country	:	US
Telephone Number	:	916-691-2069
Fax Number	:	916-691-2065

Provider Business Practice Location Address
First Line	:	9300 W STOCKTON BLVD
Second Line	:	SUITE # 104
City	:	ELK GROVE
State	:	CA
Zip	:	95758-8070
Country	:	US
Telephone Number	:	916-691-2069
Fax Number	:	916-691-2065

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. STEPHEN WILLIAM KENNEDY
Credential	:	MD
Telephone Number	:	916-691-2069

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	11/09/2009

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