MEDICARE: RYAN KENNEDY DPT

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	PT37122	FL
2	225100000X	Physical Therapist	044900	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT37122	OTHER	FL	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629627740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN KENNEDY DPT

Provider Business Mailing Address
First Line	:	15 APEX DR
Second Line	:
City	:	HIGHLAND
State	:	IL
Zip	:	62249-1282
Country	:	US
Telephone Number	:	618-651-0444
Fax Number	:	618-654-5439

Provider Business Practice Location Address
First Line	:	6724 FOREST HILL BLVD
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33413-3335
Country	:	US
Telephone Number	:	561-433-2009
Fax Number	:

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

Provider Enumeration Date	:	09/11/2019
Last Update Date	:	08/25/2021

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