Provider Demographics
NPI:1275541252
Name:KENNETH W. BACKSTRAND & ASSOCIATES, MD,PA
Entity Type:Organization
Organization Name:KENNETH W. BACKSTRAND & ASSOCIATES, MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-418-1004
Mailing Address - Street 1:PO BOX 60719
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906
Mailing Address - Country:US
Mailing Address - Phone:239-418-1004
Mailing Address - Fax:239-275-9080
Practice Address - Street 1:2721 DEL PRADO BLVD
Practice Address - Street 2:STE 100
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904
Practice Address - Country:US
Practice Address - Phone:239-242-8010
Practice Address - Fax:239-242-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050622207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046206300Medicaid
FL046206300Medicaid
R14435Medicare UPIN