Active NPI
Thomas James Kennedy III, M.D.
- Plastic Surgery Physician
- Bridgeport, WV
National Provider Identifier
1215033402
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Plastic Surgery Physician
- License
- WV20534
- Practice address
- 527 Medical Park Dr
Suite 203
Bridgeport, WV 26330-9007 - Phone
- (681) 342-3190
- NPI assigned
- Sep 15, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Plastic Surgery Physician | 208200000X | WV20534 | WV | Primary |
| Surgery of the Hand (Plastic Surgery) Physician | 2082S0105X | 20534 | WV |
Addresses
Primary practice location
527 Medical Park Dr
Suite 203
Bridgeport, WV 26330-9007
Mailing address
527 Medical Park Dr
Suite 203
Bridgeport, WV 26330-9007
Phone (681) 342-3190
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 550781237 | Other | WV | TAX ID |
| 350670000 | Other | WV | FEDWORKER'S COMPENSATION |
| 3002519000 | Medicaid | WV | |
| WV20534 | Other | WV | HEALTH PLAN |
| 1056649 | Other | WV | WORKER'S COMP BRICK ST |
| 001722749 | Other | WV | BLUE CROSS/BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| WV20534 | WV | MD | Plastic Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158278400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1307491200000",
"number": "1215033402",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "527 MEDICAL PARK DR",
"address_2": "SUITE 203",
"city": "BRIDGEPORT",
"state": "WV",
"postal_code": "263309007",
"telephone_number": "681-342-3190",
"fax_number": "681-342-3195"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "527 MEDICAL PARK DR",
"address_2": "SUITE 203",
"city": "BRIDGEPORT",
"state": "WV",
"postal_code": "263309007",
"telephone_number": "681-342-3190"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KENNEDY",
"first_name": "THOMAS",
"middle_name": "JAMES",
"name_prefix": "Dr.",
"name_suffix": "III",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-09-15",
"last_updated": "2011-06-08",
"status": "A"
},
"taxonomies": [
{
"code": "208200000X",
"taxonomy_group": "",
"desc": "Plastic Surgery",
"state": "WV",
"license": "WV20534",
"primary": true
},
{
"code": "2082S0105X",
"taxonomy_group": "",
"desc": "Plastic Surgery, Surgery of the Hand",
"state": "WV",
"license": "20534",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TAX ID",
"identifier": "550781237",
"state": "WV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FEDWORKER'S COMPENSATION",
"identifier": "350670000",
"state": "WV"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3002519000",
"state": "WV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTH PLAN",
"identifier": "WV20534",
"state": "WV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WORKER'S COMP BRICK ST",
"identifier": "1056649",
"state": "WV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS/BLUE SHIELD",
"identifier": "001722749",
"state": "WV"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bridgeport, WV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 8, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.