Provider Demographics
NPI:1275515298
Name:WIENCEK, KENNETH CARL (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CARL
Last Name:WIENCEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:715 S HEALTH PKWY
Practice Address - Street 2:MEDICAL OFFICE BUILDING 3
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8352
Practice Address - Country:US
Practice Address - Phone:269-273-8471
Practice Address - Fax:269-273-9680
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-07-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101015914207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG56008 109Medicare ID - Type Unspecified
MIE75907Medicare UPIN
MI4601958 11Medicare ID - Type Unspecified