Provider Demographics
NPI:1891703559
Name:GOLD, KENNETH I (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:GOLD
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 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7394
Practice Address - Street 1:1905 E. HUEBBE PARKWAY
Practice Address - Street 2:BELOIT HEALTH SYSTEM INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-363-7394
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16384020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10639OtherDEAN HEALTH PLAN HMO
WI1891703559Medicaid
B53119Medicare UPIN