Provider Demographics
NPI:1376530386
Name:FUGATE, KENNETH K (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:K
Last Name:FUGATE
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 1:525 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2581
Mailing Address - Country:US
Mailing Address - Phone:814-938-7933
Mailing Address - Fax:814-938-9872
Practice Address - Street 1:525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2581
Practice Address - Country:US
Practice Address - Phone:814-938-7933
Practice Address - Fax:814-938-9872
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039731L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA010053900OtherBLACK LUNG
PA126846OtherBLUE SHIELD GROUP #
PA251819235OtherCOMMERICAL INSURANCES
PAP0000958OtherGATEWAY
PA211751OtherUPMC
PA0010556490006Medicaid
PA003158OtherBLUE SHIELD INDIVIDUAL #
PA251819235001OtherTRICARE
PA3733OtherHEALTHEON/HEALTHAMERICA
PA003158Medicare PIN
PA3733OtherHEALTHEON/HEALTHAMERICA
PA251819235001OtherTRICARE