Provider Demographics
NPI:1508863747
Name:KRUPP, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KRUPP
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 1:5308 HARROUN RD
Mailing Address - Street 2:SUITE 055
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2114
Mailing Address - Country:US
Mailing Address - Phone:419-824-6599
Mailing Address - Fax:419-885-3870
Practice Address - Street 1:5308 HARROUN RD
Practice Address - Street 2:SUITE 055
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2114
Practice Address - Country:US
Practice Address - Phone:419-824-6599
Practice Address - Fax:419-885-3870
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046209207RH0003X
MI4301079387207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560290Medicaid
OHKR0586193OtherMEDICARE
OHP00812603OtherRRMC
OHP00812603OtherRRMC
OHKR0586193OtherMEDICARE
OH0586197Medicare PIN