Provider Demographics
NPI:1902849151
Name:HILL, KENNETH OWEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:OWEN
Last Name:HILL
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 1:110 HO PLZ
Mailing Address - Street 2:GANNETT HEALTH SERVICES
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853-3102
Mailing Address - Country:US
Mailing Address - Phone:607-255-6106
Mailing Address - Fax:607-254-3503
Practice Address - Street 1:110 HO PLAZA
Practice Address - Street 2:GANNETT HEALTH SERVICES
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853
Practice Address - Country:US
Practice Address - Phone:607-255-6106
Practice Address - Fax:607-254-3503
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00450099OtherRR MEDICARE
NY01083247Medicaid
NYP00450099OtherRR MEDICARE
NYRB5817Medicare PIN