Provider Demographics
NPI:1093731440
Name:ELSON, KENNETH H (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:ELSON
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 1044
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-1044
Mailing Address - Country:US
Mailing Address - Phone:402-630-5100
Mailing Address - Fax:
Practice Address - Street 1:755 HONEYSUCKLE RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-2745
Practice Address - Country:US
Practice Address - Phone:402-630-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE130662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0915579Medicaid
MO206812802Medicaid
NE088498EIMedicare ID - Type Unspecified
MO206812802Medicaid