Basic Information
| Provider Information | |||||||||
| NPI: | 1992733224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | DAMON | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706241800 | ||||||||
| FaxNumber: | 9706241891 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706241800 | ||||||||
| FaxNumber: | 9706241891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | DR.0047892 | CO | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 10460A | WY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | L2368 | TX | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 2080P0202X | 47892 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2086S0120X | 47892 | CO | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 208600000X | DR.0047892 | CO | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 68856750 | 05 | CO | MEDICAID | 10025839700 | 05 | NE | MEDICAID |