Provider Demographics
NPI:1487943098
Name:KENNEDY, STEPHEN ALAN (MD, FRCSC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ALAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD, FRCSC
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:4245 ROOSEVELT WAY NE
Practice Address - Street 2:BOX 354740
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6008
Practice Address - Country:US
Practice Address - Phone:206-598-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60302144207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1487943098Medicaid
WAPENDINGOtherL&I
WAPENDINGMedicare PIN