Individual
DR. THOMAS JAMES KENNEDY III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
527 MEDICAL PARK DR, SUITE 203, BRIDGEPORT, WV 26330-9007
(681) 342-3190
Mailing address
527 MEDICAL PARK DR, SUITE 203, BRIDGEPORT, WV 26330-9007
(681) 342-3190
(681) 342-3195
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
WV20534
WV
2082S0105X
Surgery of the Hand (Plastic Surgery) Physician
20534
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001722749
BLUE CROSS/BLUE SHIELD
WV
01
—
1056649
WORKER'S COMP BRICK ST
WV
05
—
3002519000
—
WV
01
—
350670000
FEDWORKER'S COMPENSATION
WV
01
—
550781237
TAX ID
WV
01
—
WV20534
HEALTH PLAN
WV
Enumeration date
09/15/2006
Last updated
06/08/2011
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