Basic Information
| Provider Information | |||||||||
| NPI: | 1548392962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51322 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421025622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707771550 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 W PROFESSIONAL PARK CT | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708435300 | ||||||||
| FaxNumber: | 2708435383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 003567 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.