Provider Demographics
NPI:1164401592
Name:BESCAK, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:BESCAK
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:294 W STATE ROUTE 89A
Practice Address - Street 2:SUITE 107
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3754
Practice Address - Country:US
Practice Address - Phone:928-634-1331
Practice Address - Fax:928-634-3130
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036051207RC0000X
AZ40903207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE36051OtherSUMMA
OH0413832Medicaid
OH000000128703OtherANTHEM
OH100402OtherKAISER
AZ413507Medicaid
060013315OtherRAILROAD MEDICARE #
OH341221800045OtherCARESOURCE
AZZ92438Medicare PIN
OH100402OtherKAISER
OH0413832Medicaid
OH000000128703OtherANTHEM