Provider Demographics
NPI:1518984137
Name:STANLEY, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:STANLEY
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 1:1220 E ELM ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2803
Mailing Address - Country:US
Mailing Address - Phone:419-228-0570
Mailing Address - Fax:419-228-0943
Practice Address - Street 1:1220 E ELM ST STE 101
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2803
Practice Address - Country:US
Practice Address - Phone:419-228-0570
Practice Address - Fax:419-228-0943
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH057809208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000027893OtherANTHEM
340008614OtherRAILROAD MEDICARE
OH0989757Medicaid
OH0766683Medicare PIN
OH0989757Medicaid