Provider Demographics
NPI:1861491805
Name:REED, KENNETH W (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:REED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9660 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-365-1166
Mailing Address - Fax:219-365-8852
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:ST JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:219-365-1166
Practice Address - Fax:219-365-8852
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002051A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0091143293OtherBCBS OF ILLINOIS
IN080178952OtherMEDICARE RAILROAD
IN000000203724OtherANTHEM BCBS
IN200341680Medicaid
H27903Medicare UPIN
IN000000203724OtherANTHEM BCBS