Provider Demographics
NPI:1740217850
Name:MEISNER, KENNETH WILLIAM (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WILLIAM
Last Name:MEISNER
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:121 CENTER GROVE RD
Mailing Address - Street 2:SUITE #18
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4453
Mailing Address - Country:US
Mailing Address - Phone:973-328-1414
Mailing Address - Fax:973-361-1085
Practice Address - Street 1:121 CENTER GROVE RD
Practice Address - Street 2:SUITE #18
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-4453
Practice Address - Country:US
Practice Address - Phone:973-328-1414
Practice Address - Fax:973-361-1085
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03450600208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ142500Medicaid
NJC56479Medicare UPIN
NJC56479Medicare ID - Type Unspecified