Provider Demographics
NPI:1023682416
Name:RADERSTORF, KENNETH FRANCIS III (NP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:FRANCIS
Last Name:RADERSTORF
Suffix:III
Gender:M
Credentials:NP
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Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:547-647-2129
Mailing Address - Fax:
Practice Address - Street 1:3301 COUNTY ROAD 6 E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-7673
Practice Address - Country:US
Practice Address - Phone:574-266-5342
Practice Address - Fax:574-266-5847
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28222082A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300065926Medicaid
ININ4223039OtherMEDICARE