Provider Demographics
NPI:1629163217
Name:KENNETH L GWINN MD PC
Entity Type:Organization
Organization Name:KENNETH L GWINN 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:L
Authorized Official - Last Name:GWINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-799-1212
Mailing Address - Street 1:1976 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5319
Mailing Address - Country:US
Mailing Address - Phone:586-799-1212
Mailing Address - Fax:
Practice Address - Street 1:48681 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-799-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKG050974207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC7134OtherMCARE HMO
MI0405011981OtherBCBS OF MICHIGAN
MI12795880Medicaid
MI000000009639OtherCAPE HEALTH
MI102795880OtherGREAT LAKES HEALTH PLAN
MI258611OtherOMNICARE
MI131442OtherPREFERRED CHOICES
MIC7134OtherMCARE HMO
MI12795880Medicaid