Basic Information
| Provider Information | |||||||||
| NPI: | 1558324160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | MERLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 560 N CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430829105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148392300 | ||||||||
| FaxNumber: | 6148392301 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 N CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430829105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148392300 | ||||||||
| FaxNumber: | 6148392301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 35047762K | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 35047762K | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0005X | 35047762K | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000120033 | 01 | OH | ANTHEM PIN | OTHER | 09-00371 | 01 | OH | UHC PIN | OTHER | 4066846 | 01 | OH | AETNA PIN | OTHER | KE0731251 | 01 | OH | RAILROAD MEDICARE | OTHER | 854875 | 05 | OH | MEDICAID | 1881292-002 | 01 | OH | CIGNA PIN | OTHER | 1376868448 | 01 | OH | MEDICARE DME | OTHER |