Provider Demographics
NPI:1073522314
Name:KENNETH W. CHIN, M.D., INCORPORATED
Entity Type:Organization
Organization Name:KENNETH W. CHIN, M.D., INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-705-0745
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE120
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-817-7707
Mailing Address - Fax:818-817-7727
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE120
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-817-7707
Practice Address - Fax:818-817-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG296602085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G296600OtherBLUE SHIELD
CA00G296600Medicaid
CAGR0106039Medicaid
CAWG29660EEMedicare PIN
CAGR0106039Medicaid
CAWG29660WMedicare PIN
CABU740YMedicare PIN
CAA44101Medicare UPIN
CA00G296600Medicaid
CATP051AMedicare PIN
CA00G296600OtherBLUE SHIELD
CAWG29660TMedicare PIN
CAWG29660UMedicare PIN
CABU740ZMedicare PIN