Provider Demographics
NPI:1710960414
Name:BEASLEY, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9370
Mailing Address - Fax:315-870-9364
Practice Address - Street 1:1226 E WATER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1155
Practice Address - Country:US
Practice Address - Phone:315-478-4185
Practice Address - Fax:315-478-0840
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2020-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY39575208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I01793Medicare UPIN
KY0986002Medicare PIN