MEDICARE: LOFTON KENNEDY JR. 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
1	207V00000X	Obstetrics & Gynecology Physician		IL

General Provider Information

NPI Number	:	1770533838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOFTON KENNEDY JR. MD

Provider Business Mailing Address
First Line	:	3601 W 183RD ST
Second Line	:
City	:	HAZEL CREST
State	:	IL
Zip	:	60429-2409
Country	:	US
Telephone Number	:	708-957-7623
Fax Number	:	708-957-7948

Provider Business Practice Location Address
First Line	:	175 E DELAWARE PL
Second Line	:	SUITE 5024
City	:	CHICAGO
State	:	IL
Zip	:	60611-1756
Country	:	US
Telephone Number	:	312-944-0577
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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