1720033319 NPI number — TIMOTHY ROBERT KENNEDY M.D.

Table of content: TIMOTHY ROBERT KENNEDY M.D. (NPI 1720033319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720033319 NPI number — TIMOTHY ROBERT KENNEDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
TIMOTHY
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720033319
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9621 RIDGETOP BLVD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-8502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-782-3102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1780 NW MYHRE RD
Provider Second Line Business Practice Location Address:
SUITE 2120
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-782-3102
Provider Business Practice Location Address Fax Number:
360-782-3112
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD00027437 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 160015562 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5374029 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1277KE . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 134954 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8128431 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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