Provider Demographics
NPI:1336254879
Name:SANSOME, KENNETH NEIL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:NEIL
Last Name:SANSOME
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 1:930 NW JONES AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1314
Mailing Address - Country:US
Mailing Address - Phone:541-926-3922
Mailing Address - Fax:
Practice Address - Street 1:930 NW JONES AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1314
Practice Address - Country:US
Practice Address - Phone:541-926-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN260270900Medicaid
080120567OtherRR MEDICARE
IA0509356OtherIA MA
D48937Medicare UPIN
MN080005292Medicare ID - Type Unspecified