Provider Demographics
NPI:1639148737
Name:KENNEFICK, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:KENNEFICK
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 1:1130 NW 22ND AVE STE 640
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2993
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:9155 SW BARNES RD STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6631
Practice Address - Country:US
Practice Address - Phone:503-292-7704
Practice Address - Fax:503-292-7046
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16837207RN0300X
OR16837207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8174617Medicaid
OR021845Medicaid
WA8174617Medicaid
OR021845Medicaid