Provider Demographics
NPI:1215035605
Name:BUETTNER, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BUETTNER
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 1:28512 69TH PL
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9168
Mailing Address - Country:US
Mailing Address - Phone:262-960-5623
Mailing Address - Fax:
Practice Address - Street 1:28512 69TH PL
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9168
Practice Address - Country:US
Practice Address - Phone:262-960-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067511Medicaid
IL036067511Medicaid
ILK09027Medicare PIN