MEDICARE: DR. STEPHEN D KENNEDY D.O.

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	207Q00000X	Family Medicine Physician	5101013733	MI
2	207Q00000X	Family Medicine Physician	02001650A	IN

Other Identifiers

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

General Provider Information

NPI Number	:	1700885498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN D KENNEDY D.O.

Provider Business Mailing Address
First Line	:	5838 W BRICK RD STE 106
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-8420
Country	:	US
Telephone Number	:	574-247-1911
Fax Number	:	574-247-1912

Provider Business Practice Location Address
First Line	:	5838 W BRICK RD STE 106
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628
Country	:	US
Telephone Number	:	574-247-1911
Fax Number	:	574-247-1912

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	02/22/2019

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