Provider Demographics
NPI:1407834096
Name:LI, KENNETH C (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:225 PHYSICIANS PARK STE 400
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3923
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-727-5599
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO36185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110058386OtherTRAVELERS MEDICARE
MO201863305Medicaid
AR10968001OtherARKANSAS MEDICAID
000005487Medicare ID - Type Unspecified
AR10968001OtherARKANSAS MEDICAID