Provider Demographics
NPI:1033311774
Name:KENNEDY, SCOTT RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RICHARD
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:PO BOX 5157
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-5157
Mailing Address - Country:US
Mailing Address - Phone:360-667-3056
Mailing Address - Fax:360-666-0466
Practice Address - Street 1:400 NE MOTHER JOSEPH PL
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3200
Practice Address - Country:US
Practice Address - Phone:360-667-3056
Practice Address - Fax:360-666-0466
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL16597390200000X
WAMD60134869207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program