Healthcare Provider Details

I. General information

NPI: 1962856732
Provider Name (Legal Business Name): TIMOTHY KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPROT BLVD STE A101
MOBILE AL
36608-0000
US

IV. Provider business mailing address

1200 SOMERBY DR APT 1507
MOBILE AL
36695-5442
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-8880
  • Fax: 251-378-6222
Mailing address:
  • Phone: 251-554-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36695
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: