Provider Demographics
NPI:1912995267
Name:ELEK, KENNETH EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EUGENE
Last Name:ELEK
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1750
Practice Address - Fax:574-647-1748
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2023-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031577A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100223720Medicaid
IN080129503OtherRR MEDICARE
IN000000085137OtherBCBS BMG E BLAIR WARNER
IN000000488796OtherBCBS CENTRAL
IND94926Medicare UPIN
IN178420GGMedicare PIN
IN080129503OtherRR MEDICARE
IN162520QMedicare PIN