Provider Demographics
NPI:1003870171
Name:MANNING, KENNETH RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RUSSELL
Last Name:MANNING
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:PO BOX 42935
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-2935
Mailing Address - Country:US
Mailing Address - Phone:910-609-6910
Mailing Address - Fax:910-609-5219
Practice Address - Street 1:1638 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3424
Practice Address - Country:US
Practice Address - Phone:910-609-6910
Practice Address - Fax:910-609-5219
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32779207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891297EMedicaid
NC1297EOtherBCBS
NC241422EMedicare ID - Type Unspecified
NC891297EMedicaid