Provider Demographics
NPI:1134111537
Name:ELLINGWOOD, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:ELLINGWOOD
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 1:3719 DAUPHIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1753
Mailing Address - Country:US
Mailing Address - Phone:251-414-5665
Mailing Address - Fax:251-414-5571
Practice Address - Street 1:3719 DAUPHIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1753
Practice Address - Country:US
Practice Address - Phone:251-414-5665
Practice Address - Fax:251-414-5571
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00008683174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000014586Medicaid
1134111537OtherNPI
AL920002054OtherRR MEDICARE
AL000014586Medicare PIN
AL000014586Medicare ID - Type Unspecified
AL000014586Medicaid