Provider Demographics
NPI:1215033402
Name:KENNEDY, THOMAS JAMES III (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:KENNEDY
Suffix:III
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 1:527 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9007
Mailing Address - Country:US
Mailing Address - Phone:681-342-3190
Mailing Address - Fax:681-342-3195
Practice Address - Street 1:527 MEDICAL PARK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9007
Practice Address - Country:US
Practice Address - Phone:681-342-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV20534208200000X
WV205342082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550781237OtherTAX ID
WV350670000OtherFEDWORKER'S COMPENSATION
WV3002519000Medicaid
WVWV20534OtherHEALTH PLAN
WV1056649OtherWORKER'S COMP BRICK ST
WV001722749OtherBLUE CROSS/BLUE SHIELD
WV1056649OtherWORKER'S COMP BRICK ST
WV3002519000Medicaid