Provider Demographics
NPI:1629043542
Name:KENNEDY, CHRISTOPHER THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6801 W 16TH ST
Mailing Address - Street 2:SUITE 101, ATTN:SUE
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-378-8000
Mailing Address - Fax:970-378-8088
Practice Address - Street 1:2420 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6004
Practice Address - Country:US
Practice Address - Phone:970-353-7668
Practice Address - Fax:970-353-2801
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01296177Medicaid
E40572Medicare UPIN
CO01296177Medicaid