Provider Demographics
NPI:1023092756
Name:KENNEDY, THOMAS P (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:KENNEDY
Suffix:
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 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:
Practice Address - Street 1:400 E PIONEER
Practice Address - Street 2:STE 208
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3255
Practice Address - Country:US
Practice Address - Phone:253-445-5828
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019899207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00106840Medicare ID - Type Unspecified
WAA79223Medicare UPIN