Provider Demographics
NPI:1649249129
Name:MOLLER, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MOLLER
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 1:430 BATH RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2656
Mailing Address - Country:US
Mailing Address - Phone:207-442-0350
Mailing Address - Fax:207-442-0355
Practice Address - Street 1:430 BATH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2656
Practice Address - Country:US
Practice Address - Phone:207-442-0350
Practice Address - Fax:207-442-0355
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010262207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME030024Medicare ID - Type Unspecified
ME1006390001Medicare NSC
MEB76288Medicare UPIN