Provider Demographics
NPI:1568433720
Name:KENNEDY, TIMOTHY J (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 15TH STREET PL
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3961
Mailing Address - Country:US
Mailing Address - Phone:309-797-5700
Mailing Address - Fax:
Practice Address - Street 1:1712 15TH STREET PL
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3961
Practice Address - Country:US
Practice Address - Phone:309-797-5700
Practice Address - Fax:309-762-4645
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-003971111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003971Medicaid
IL038003971Medicaid
ILT37548Medicare UPIN
IL207268Medicare ID - Type UnspecifiedGROUP