Provider Demographics
NPI:1043219694
Name:KENNEDY, ROBERT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:G15
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-2722
Mailing Address - Fax:208-239-3759
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:G15
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2722
Practice Address - Fax:208-239-3759
Is Sole Proprietor?:No
Enumeration Date:2005-07-16
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM42412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C47841Medicare UPIN
1114007Medicare ID - Type Unspecified