Basic Information
| Provider Information | |||||||||
| NPI: | 1407821424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919379 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328919379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444531406 | ||||||||
| FaxNumber: | 7726213180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 7TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278251100 | ||||||||
| FaxNumber: | 7702374926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME61941 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 174400000X | ME61941 | FL | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 26874U | 01 | FL | FL MEDICARE | OTHER | 26874 | 01 | FL | FL BCBS | OTHER | P01478716 | 01 | FL | FL MEDICARE RAILROAD PTAN | OTHER | 376073100 | 05 | FL | MEDICAID |