Provider Demographics
NPI:1215996459
Name:KENNELLY, MICHAEL M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16233 SYLVESTER RD SW STE 110
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3044
Mailing Address - Country:US
Mailing Address - Phone:206-901-8980
Mailing Address - Fax:
Practice Address - Street 1:16233 SYLVESTER RD SW STE 110
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3044
Practice Address - Country:US
Practice Address - Phone:206-901-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1005224Medicaid
WAAB24585Medicare ID - Type Unspecified