Provider Demographics
NPI:1669479846
Name:TUCKER, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TUCKER
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 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-751-2072
Mailing Address - Fax:586-751-1302
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-751-2072
Practice Address - Fax:586-751-1302
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301024231207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H273300OtherBCBSM
MI1672544Medicaid
MIKT024231OtherBCBSM OTHER IDENTIFIER
MI1672544Medicaid
B45204Medicare UPIN
MI0M01690002Medicare PIN