Provider Demographics
NPI:1023039468
Name:LITTLE, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:LITTLE
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-367-2968
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-5500
Practice Address - Fax:208-381-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2012-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8861207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010152057OtherREGENCE BLUE SHIELD
OR269560OtherOMAP
ID8J190OtherBLUE CROSS OF IDAHO GROUP
WA0203233OtherWA DEPARTMENT OF LABOR
ID860902000Medicaid
610978600OtherUS DEPARTMENT OF LABOR
ID807732400Medicaid
ID74906OtherBLUE CROSS OF IDAHO
ID860902000Medicaid
IDP00644210Medicare PIN
000010152057OtherREGENCE BLUE SHIELD
ID11268771Medicare PIN