Provider Demographics
NPI:1689796369
Name:KENNETH N. AZAN, M.D., PC
Entity Type:Organization
Organization Name:KENNETH N. AZAN, M.D., 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:NAJEEB
Authorized Official - Last Name:AZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-827-2535
Mailing Address - Street 1:1718 S INGRAM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7505
Mailing Address - Country:US
Mailing Address - Phone:660-827-2535
Mailing Address - Fax:660-826-5228
Practice Address - Street 1:1718 S INGRAM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7505
Practice Address - Country:US
Practice Address - Phone:660-827-2535
Practice Address - Fax:660-826-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6443207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO06594013OtherBLUE CROSS BLUE SHIELD KC
MOC50295Medicare UPIN
MO0003331Medicare ID - Type Unspecified