Provider Demographics
NPI:1851351472
Name:BAILEY, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:BAILEY
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 1:12210 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9211
Mailing Address - Country:US
Mailing Address - Phone:865-985-7186
Mailing Address - Fax:
Practice Address - Street 1:12210 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9211
Practice Address - Country:US
Practice Address - Phone:865-985-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0434202085R0202X
FLME940582085R0202X
GA0562612085R0202X
IL361134102085R0202X
IN01060500A2085R0202X
KY393782085R0202X
MA2241942085R0202X
NC2005006492085R0202X
NJ25MA079744002085R0202X
OH350860922085R0202X
PAMD4260192085R0202X
VA01012380492085R0202X
WV214142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA518461891AMedicaid
GAP00475523Medicare PIN
FLAC711ZMedicare PIN
GA518461891AMedicaid