Provider Demographics
NPI:1922150697
Name:GUIDERA, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:GUIDERA
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:P.O. BOX 209036
Mailing Address - Street 2:SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-9036
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:2025 E RIVER PKWY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3604
Practice Address - Country:US
Practice Address - Phone:612-596-6187
Practice Address - Fax:612-339-7634
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47329207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN158417100Medicaid
MN1922150697Medicaid
MN158417100Medicaid