Provider Demographics
NPI:1891727244
Name:DUDLEY, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:DUDLEY
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 1:1787 GRAND RIDGE CT NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-774-8131
Mailing Address - Fax:616-774-8204
Practice Address - Street 1:1787 GRAND RIDGE CT NE
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-774-8131
Practice Address - Fax:616-774-8204
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0004553974OtherAETNA
MI900000696OtherPRIORITY HEALTH
MI0D17690OtherBLUE CROSS BLUE SHIELD
MI2957039Medicaid
MI900000696OtherPRIORITY HEALTH
0D1769004Medicare ID - Type Unspecified