Provider Demographics
NPI:1417985631
Name:KENNEDY, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
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 1:2034 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9313
Mailing Address - Country:US
Mailing Address - Phone:920-621-1785
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD STE 240
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8280
Practice Address - Fax:920-288-8285
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29987208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3402100592OtherBCBS
MI104386126Medicaid
WI31501900Medicaid
WI340015995OtherRAILROAD
MI104386153Medicaid
MI104386126Medicaid
WID97454Medicare UPIN
MIM82740003Medicare PIN