Provider Demographics
NPI:1851389274
Name:MINTZ, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:MINTZ
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:RIVERSIDE ASSOCIATES IN ANESTHESIA
Mailing Address - Street 2:40 FRONT STREET
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-722-7264
Mailing Address - Fax:607-722-7869
Practice Address - Street 1:RIVERSIDE ASSOCIATES IN ANESTHESIA
Practice Address - Street 2:40 FRONT STREET
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905
Practice Address - Country:US
Practice Address - Phone:607-722-7264
Practice Address - Fax:607-722-7869
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181411207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCAN131411OtherWORKERS COMP
NY01191377Medicaid
E62698Medicare UPIN
NY34565RMedicare ID - Type Unspecified