Provider Demographics
NPI:1053529008
Name:SCOTT A KENNEDY OD PC
Entity type:Organization
Organization Name:SCOTT A KENNEDY OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD PC
Authorized Official - Phone:814-827-7931
Mailing Address - Street 1:PO BOX 285
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-0285
Mailing Address - Country:US
Mailing Address - Phone:814-827-7931
Mailing Address - Fax:
Practice Address - Street 1:122 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1761
Practice Address - Country:US
Practice Address - Phone:814-827-7931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000659152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA410042928OtherPALMETTO GBA
PAT30300Medicare UPIN
PA418623Medicare PIN
PA410042928OtherPALMETTO GBA