Provider Demographics
NPI:1710565619
Name:KENNEDY, TIMOTHY I (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KENNEDY
Suffix:I
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 HOLIDAY INN RD
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-4034
Mailing Address - Country:US
Mailing Address - Phone:814-375-2200
Mailing Address - Fax:814-375-2848
Practice Address - Street 1:265 HOLIDAY INN RD
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-4034
Practice Address - Country:US
Practice Address - Phone:814-371-2200
Practice Address - Fax:814-372-2573
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS024092207Q00000X
390200000X
PAOT021236390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program