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NPI Code Detail

MEDICARE: OLGA VLADIMIROVNA KENNEDY MD

MEDICARE: OLGA VLADIMIROVNA KENNEDY MD
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
1207R00000XInternal Medicine Physician01061208AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1699742122
Entity Type Code : Individual
Provider Name (Legal Business Name) : OLGA VLADIMIROVNA KENNEDY MD
Provider Business Mailing Address
First Line : 3551 ROGER BROOKE DR
Second Line :
City : JBSA FT SAM HOUSTON
State : TX
Zip : 78234-4504
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4420 76TH ST NE
Second Line :
City : MARYSVILLE
State : WA
Zip : 98270-3726
Country : US
Telephone Number : 360-651-7490
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/03/2006
Last Update Date : 08/21/2018

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