Provider Demographics
NPI:1053343111
Name:KENNEDY, DEBBIE ANN V (MD)
Entity type:Individual
Prefix:
First Name:DEBBIE
Middle Name:ANN
Last Name:KENNEDY
Suffix:V
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3718
Mailing Address - Country:US
Mailing Address - Phone:518-438-1434
Mailing Address - Fax:518-489-1205
Practice Address - Street 1:4 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3718
Practice Address - Country:US
Practice Address - Phone:518-438-1434
Practice Address - Fax:518-489-1205
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10045547OtherVERMONT MEDICAID
NY19201OtherMVP HEALTH PLAN
NY67314OtherGHI HMO SELECT
NY00040065801OtherUNIVERA HEALTH CARE
NY141826445OtherHUMANA
NYDK04611510OtherEMPIRE BC/BS
NY000406385003OtherBS NENY
NY01274744Medicaid
NY10001038OtherCDPHP
NY20103980OtherFIDELIS CARE NEW YORK
NY67314OtherGHI HMO SELECT
NYE94388Medicare UPIN