Provider Demographics
NPI:1649298134
Name:KENNEDY, KEVIN S (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 SO UNION AVE
Mailing Address - Street 2:#2-C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1953
Mailing Address - Country:US
Mailing Address - Phone:253-627-7567
Mailing Address - Fax:253-627-4778
Practice Address - Street 1:1818 SO UNION AVE
Practice Address - Street 2:#2-C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1953
Practice Address - Country:US
Practice Address - Phone:253-627-7567
Practice Address - Fax:253-627-4778
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001295207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1072040Medicaid
WA72498OtherDEPT OF LABOR & INDUSTRY
WAKE4773OtherREGENCE BLUE SHIELD
WA1072040Medicaid