Basic Information
| Provider Information | |||||||||
| NPI: | 1841288701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
| FaxNumber: | 2693418743 | ||||||||
| Practice Location | |||||||||
| Address1: | 52375 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MATTAWAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490719332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696683348 | ||||||||
| FaxNumber: | 2696687702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 01/11/2013 | ||||||||
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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 | 363A00000X | 5601002670 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1841288701 | 05 | MI | MEDICAID | 700H060020 | 01 | MI | BCBSM | OTHER |