Provider Demographics
NPI:1518125608
Name:KENNETH W DISTLER MD PC
Entity Type:Organization
Organization Name:KENNETH W DISTLER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:DISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-799-0600
Mailing Address - Street 1:2130 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3351
Mailing Address - Country:US
Mailing Address - Phone:989-799-0600
Mailing Address - Fax:989-799-6080
Practice Address - Street 1:2130 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3351
Practice Address - Country:US
Practice Address - Phone:989-799-0600
Practice Address - Fax:989-799-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1681561Medicaid
MI1681561Medicaid
MIE26233Medicare UPIN