Provider Demographics
NPI:1639141799
Name:STOUTENBOROUGH, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:STOUTENBOROUGH
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:PO BOX 2548
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-2548
Mailing Address - Country:US
Mailing Address - Phone:229-312-5800
Mailing Address - Fax:229-312-5853
Practice Address - Street 1:500 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1985
Practice Address - Country:US
Practice Address - Phone:229-312-7800
Practice Address - Fax:229-312-7505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050062207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB30317Medicare UPIN
GA83BBBQZMedicare ID - Type Unspecified