Basic Information
| Provider Information | |||||||||
| NPI: | 1750341459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5166 DIXBORO FARMS DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347618775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481971051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347123325 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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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 | 208000000X | 4301405919 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 4301405919 | MI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1944760 | 05 | MI | MEDICAID | 700H161150 | 01 | MI | BLUE SHIELD | OTHER |