Provider Demographics
NPI:1356450241
Name:GOERTZ, KENNETH K (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:GOERTZ
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 1:3901 RAINBOW BLVD
Mailing Address - Street 2:4070 DELP MAIL STOP 4017
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-7816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:2026 MILLER MAIL STOP 4004
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-6301
Practice Address - Fax:913-588-6319
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
110129358OtherRAILROAD MEDICARE
MO201128808Medicaid
MO09325014OtherBCBS KANSAS CITY
KS625860OtherFIRSTGUARD
KS100168740AMedicaid
110129358OtherRAILROAD MEDICARE
MO201128808Medicaid