Provider Demographics
NPI:1639119845
Name:PATRICK, KENNETH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:PATRICK
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:DEPT 2215
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-0001
Mailing Address - Country:US
Mailing Address - Phone:800-553-4924
Mailing Address - Fax:
Practice Address - Street 1:1024 LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3913
Practice Address - Country:US
Practice Address - Phone:800-553-4924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44174207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00394962OtherRAILROAD MEDICARE
WY123463300Medicaid
CO64435865Medicaid
COS5008OtherBCBS
COP00394962OtherRAILROAD MEDICARE
CO64435865Medicaid