Provider Demographics
NPI:1043206758
Name:MALMSTROM, KENNETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:MALMSTROM
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 1:1101 MEDICAL CENTER BLVD.
Mailing Address - Street 2:HOSPITALIST DEPARTMENT
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-1656
Mailing Address - Fax:504-349-1933
Practice Address - Street 1:1101 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3147
Practice Address - Country:US
Practice Address - Phone:504-349-1656
Practice Address - Fax:504-349-1933
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.14714R208M00000X
LA14714R208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09288765Medicaid
LA1148571Medicaid
LA4E605Medicare ID - Type Unspecified
LAH72148Medicare UPIN
MS09288765Medicaid