Provider Demographics
NPI:1265549422
Name:LEVIN, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:LEVIN
Suffix:
Gender:M
Credentials:MD
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6777 W MAPLE RD
Mailing Address - Street 2:DEPT OF RADIATION ONCOLOGY HENRY FORD HOSPITAL
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-661-6487
Mailing Address - Fax:248-661-7164
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:DEPT OF RADIATION ONCOLOGY HENRY FORD HOSPITAL
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-661-6487
Practice Address - Fax:248-661-7164
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301058146207R00000X, 2085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
700H262300OtherBLUE CROSS-BLUE CROSS
KL058146OtherCHAMPUS-CHAMPUS
MI488605210Medicaid
KL058146OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262300OtherBLUE CROSS-BLUE CROSS
E94939Medicare UPIN