Provider Demographics
NPI:1679512313
Name:KENNEDY, SUSAN LUCILLE (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LUCILLE
Last Name:KENNEDY
Suffix:
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:PO BOX 19368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-9368
Mailing Address - Country:US
Mailing Address - Phone:919-787-8221
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6504
Practice Address - Country:US
Practice Address - Phone:919-787-8221
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-02912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7228732OtherVIRGINIA MEDICAID
NC16-54610OtherUNITED HEALTHCARE
NC16-54611OtherUNITED HEALTHCARE
NC48598OtherBLUECROSS BLUESHIELD
NC64590OtherMEDCOST
NC8948598Medicaid
NC64580OtherMEDCOST
NC64587OtherMEDCOST
NC16-54612OtherUNITED HEALTHCARE
NC2223816BMedicare ID - Type Unspecified
NC8948598Medicaid
NC2223816CMedicare ID - Type Unspecified
G09478Medicare UPIN