Provider Demographics
NPI:1164450516
Name:HARROLD, KEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:HARROLD
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 2505
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-2505
Mailing Address - Country:US
Mailing Address - Phone:888-828-3197
Mailing Address - Fax:
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-983-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75-51207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
189008OtherRIO PRIMARY CARE
NM00022160Medicaid
2359OtherLOVELACE
14924OtherPRESBY- TERIAN
$$$$$$$$$Medicare PIN
F61073Medicare UPIN
930049661Medicare ID - Type UnspecifiedRAILROAD MEDICARE
374605107Medicare PIN