Provider Demographics
NPI:1639232176
Name:KENNETH W KOREY MD PA
Entity Type:Organization
Organization Name:KENNETH W KOREY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KOREY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:321-636-8241
Mailing Address - Street 1:1022 FLORIDA AVE S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2145
Mailing Address - Country:US
Mailing Address - Phone:321-636-8241
Mailing Address - Fax:
Practice Address - Street 1:1022 FLORIDA AVE S
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2145
Practice Address - Country:US
Practice Address - Phone:321-636-8241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057749900Medicaid
FL407113416OtherRAILROAD MEDICARE
FL15359OtherBLUE CROSS BLUE SHIELD FL
FLD52538Medicare UPIN
FL057749900Medicaid