Active NPI
Brad Lee Kennedy, LMP
- Contractor
- Vancouver, WA
National Provider Identifier
1356628630
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Contractor
- License
- MA60188011
- Practice address
- 2402 Broadway St
Vancouver, WA 98663-3229 - Phone
- (360) 241-6630
- NPI assigned
- Nov 15, 2011
- 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 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor | 171W00000X | MA60188011 | WA | Primary |
Addresses
Primary practice location
2402 Broadway St
Vancouver, WA 98663-3229
Mailing address
13502 SE Harold St
Portland, OR 97236-4149
Phone (503) 933-8717
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MA60188011 | WA | MD | Contractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1321315200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1321315200000",
"number": "1356628630",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13502 SE HAROLD ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972364149",
"telephone_number": "503-933-8717"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2402 BROADWAY ST",
"city": "VANCOUVER",
"state": "WA",
"postal_code": "986633229",
"telephone_number": "360-241-6630"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KENNEDY",
"first_name": "BRAD",
"middle_name": "LEE",
"credential": "LMP",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-11-15",
"last_updated": "2011-11-15",
"status": "A"
},
"taxonomies": [
{
"code": "171W00000X",
"taxonomy_group": "",
"desc": "Contractor",
"state": "WA",
"license": "MA60188011",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Vancouver, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 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.