Provider Demographics
NPI:1508844812
Name:WELLS, KENNETH W (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:WELLS
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:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44222-0271
Mailing Address - Country:US
Mailing Address - Phone:330-923-7066
Mailing Address - Fax:330-923-8090
Practice Address - Street 1:116 EAST AVE
Practice Address - Street 2:STE 3
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2300
Practice Address - Country:US
Practice Address - Phone:330-633-7782
Practice Address - Fax:330-633-4701
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0822471Medicaid
E87005Medicare UPIN
OH0822471Medicaid
0693165Medicare PIN
0693166Medicare PIN