Provider Demographics
NPI:1407801707
Name:MEACHAM, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MEACHAM
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 1:101 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3363
Mailing Address - Country:US
Mailing Address - Phone:479-498-6583
Mailing Address - Fax:479-498-6585
Practice Address - Street 1:101 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-3363
Practice Address - Country:US
Practice Address - Phone:479-498-6583
Practice Address - Fax:479-498-6585
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4297208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106516001Medicaid
B90428Medicare UPIN
AR53603Medicare PIN