Provider Demographics
NPI:1770542441
Name:STONE, KENNETH SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:SAMUEL
Last Name:STONE
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8085
Practice Address - Street 1:1116 N 16TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2119
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8054
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036689A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9009635OtherPHCS PID NUMBER
IN10826030OtherCAQH NUMBER
IN100087540Medicaid
INST15638033Medicaid
IN000000197821OtherANTHEM PROVIDER NUMBER
IN10826030OtherCAQH NUMBER
IN142080YMedicare PIN
IN100087540Medicaid
INST15638033Medicaid
IN815500P6Medicare PIN
IN185510BMedicare PIN