Provider Demographics
NPI:1740224658
Name:KENNEDY, MICHAEL S (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5412
Mailing Address - Fax:425-259-1164
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201
Practice Address - Country:US
Practice Address - Phone:425-339-5412
Practice Address - Fax:425-259-1164
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014525207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111120483OtherMEDICARE
WA030004268OtherMEDICARE RAILROAD
WA030004279OtherRAILROAD MEDICARE
WA120835OtherCIGNA DMERC
WA030002415OtherRAILROAD MEDICARE
WA1005750Medicaid
WAKE7883OtherREGENCE
WA111120483OtherMEDICARE