Provider Demographics
NPI:1720033319
Name:KENNEDY, TIMOTHY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
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 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-782-3102
Mailing Address - Fax:
Practice Address - Street 1:1780 NW MYHRE RD
Practice Address - Street 2:SUITE 2120
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8676
Practice Address - Country:US
Practice Address - Phone:360-782-3102
Practice Address - Fax:360-782-3112
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027437207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160015562OtherRAILROAD MEDICARE
5374029OtherAETNA
1277KEOtherREGENCE BLUE SHIELD
WA134954OtherLABOR & INDUSTRIES
WA8128431Medicaid
WA8128431Medicaid
WAG000250640Medicare PIN
WAG8851914Medicare PIN
WAGAB05650Medicare PIN
WA134954OtherLABOR & INDUSTRIES
160015562OtherRAILROAD MEDICARE
G8888311Medicare PIN
E98267Medicare UPIN
G8886410Medicare PIN
5374029OtherAETNA
WAGAB05648Medicare PIN