Provider Demographics
NPI:1760489967
Name:RICH, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:RICH
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 1:1100 DRESSER COURT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:919-850-9911
Mailing Address - Fax:919-790-5524
Practice Address - Street 1:1100 DRESSER COURT
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-850-9911
Practice Address - Fax:919-790-5524
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28324207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
71528OtherBCBS
C81832Medicare UPIN
203398CMedicare ID - Type Unspecified