Provider Demographics
NPI:1003910118
Name:GWINN, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GWINN
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 1:48681 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4403
Mailing Address - Country:US
Mailing Address - Phone:586-799-1212
Mailing Address - Fax:586-799-1210
Practice Address - Street 1:48681 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4403
Practice Address - Country:US
Practice Address - Phone:586-799-1212
Practice Address - Fax:586-799-1210
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKG050974207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC7134OtherMCARE HMO
MI131442OtherPREFERRED CHOICES
MI258611OtherOMNICARE
MI000000009639OtherCAPE HEALTH
MI0405011981OtherBCBS
MI000000009639OtherCAPE HEALTH
MI258611OtherOMNICARE