Provider Demographics
NPI:1356398283
Name:KENNEDY, TIMOTHY C (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
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 1:1601 E 19TH AVE
Mailing Address - Street 2:6250
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1216
Mailing Address - Country:US
Mailing Address - Phone:303-863-0300
Mailing Address - Fax:303-863-7014
Practice Address - Street 1:1601 E 19TH AVE
Practice Address - Street 2:6250
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1216
Practice Address - Country:US
Practice Address - Phone:303-863-0300
Practice Address - Fax:303-863-7014
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO18011207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4012134Medicaid
D23368Medicare UPIN
CO4012134Medicaid