Provider Demographics
NPI:1538142765
Name:OH, KENNETH K (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:OH
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 1:2817 NEW PINERY RD.
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:608-742-0362
Practice Address - Street 1:2817 NEW PINERY RD.
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE INC
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:608-742-0362
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41268020208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32590300Medicaid
H01022Medicare UPIN
WI32590300Medicaid