Provider Demographics
NPI:1871576223
Name:KENNEDY, RAYMOND JAMES III (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JAMES
Last Name:KENNEDY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 WOODWINDS DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2522
Mailing Address - Country:US
Mailing Address - Phone:651-259-9750
Mailing Address - Fax:
Practice Address - Street 1:2040 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2522
Practice Address - Country:US
Practice Address - Phone:651-259-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN396532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN038460700Medicaid
MN1501790OtherMEDICA
MN991N7KEOtherBCBS OF MN