Provider Demographics
NPI:1801004593
Name:KENNETH E ANSELMI MD
Entity type:Organization
Organization Name:KENNETH E ANSELMI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANSELMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-963-0895
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:DORAN
Mailing Address - State:VA
Mailing Address - Zip Code:24612
Mailing Address - Country:US
Mailing Address - Phone:276-963-0895
Mailing Address - Fax:276-963-5712
Practice Address - Street 1:5433 GOVERNOR G C PEERY HWY
Practice Address - Street 2:
Practice Address - City:DORAN
Practice Address - State:VA
Practice Address - Zip Code:24612
Practice Address - Country:US
Practice Address - Phone:276-963-0895
Practice Address - Fax:276-963-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6371108Medicaid
VAC04354Medicare ID - Type Unspecified
VA6371108Medicaid