Basic Information
| Provider Information | |||||||||
| NPI: | 1255323291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 34057194 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35057194 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0634374 | 01 | OH | AETNA | OTHER | 12-01218 | 01 | OH | UHC | OTHER | 000000141232 | 01 | OH | ANTHEM | OTHER | 00625 | 01 | OH | PHC | OTHER | 0741344 | 05 | OH | MEDICAID |