Provider Demographics
NPI:1447239967
Name:EDWARDS, KENNETH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:EDWARDS
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 1:183 PEACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9146
Mailing Address - Country:US
Mailing Address - Phone:269-428-3500
Mailing Address - Fax:
Practice Address - Street 1:183 PEACE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9146
Practice Address - Country:US
Practice Address - Phone:269-428-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061344207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4554025Medicaid
MI4554025Medicaid
MIN80920005Medicare ID - Type Unspecified