Provider Demographics
NPI:1962474858
Name:HUGHES, KENNETH GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GEORGE
Last Name:HUGHES
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 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-6805
Mailing Address - Fax:952-883-6117
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1460
Practice Address - Country:US
Practice Address - Phone:952-853-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29869207Q00000X
MN34607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN373893100Medicaid
080006361Medicare ID - Type Unspecified
MN373893100Medicaid