Provider Demographics
NPI:1477598688
Name:AULT, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:AULT
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 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-523-3289
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:81 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7204
Practice Address - Country:US
Practice Address - Phone:207-885-8130
Practice Address - Fax:207-885-8110
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012169207R00000X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30201824Medicaid
MEP00004865Medicare PIN
MEMM8463Medicare PIN
MEMM9957Medicare PIN
MEMM846301Medicare PIN
MEA52869Medicare UPIN