Provider Demographics
NPI:1457547184
Name:KENNETH H. DAVIDSON, MD, PC
Entity Type:Organization
Organization Name:KENNETH H. DAVIDSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-426-9278
Mailing Address - Street 1:1415 PORTLAND AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3038
Mailing Address - Country:US
Mailing Address - Phone:585-426-9278
Mailing Address - Fax:585-338-2738
Practice Address - Street 1:1415 PORTLAND AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3038
Practice Address - Country:US
Practice Address - Phone:585-426-9278
Practice Address - Fax:585-338-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103663207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y019296OtherCHAMPUS
NY00450853Medicaid
10453OtherGHI
4273339OtherAETNA
9913OtherBLUE CROSS BLUE SHIELD
PO10103663OtherBLUE CHOICE - EXCELLUS
005002871OtherBLUE SHIELD WESTERN NY
005002871OtherCOMMUNITY BLUE
07341OtherCHOICE CARE
MD4426OtherPREFERRED CARE
RA8493Medicare PIN
BA0675Medicare PIN
4273339OtherAETNA