Provider Demographics
NPI:1881652592
Name:POEMOCEAH, KENNETH MARCUS (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARCUS
Last Name:POEMOCEAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 JACKSON ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-9121
Mailing Address - Country:US
Mailing Address - Phone:479-787-5221
Mailing Address - Fax:479-787-5613
Practice Address - Street 1:1102 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9121
Practice Address - Country:US
Practice Address - Phone:479-787-5221
Practice Address - Fax:479-787-5613
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100096320AMedicaid
AR117997001Medicaid
MO202892501Medicaid
AR54175OtherBCBS (AR)
ARP00298552OtherRAILROAD MEDICARE
OK100726240DOtherOK GROUP MEDICAID NUMBER
ARP00298552OtherRAILROAD MEDICARE
AR54175Medicare ID - Type Unspecified