Black, Kenneth A
Black, Kenneth A is an individual health care provider with primary practice located at 3630 Willowcreek Rd , Portage IN 46368-5075. He recently has only one registered license in Allopathic & Osteopathic Physicians / Family Medicine, which is considered as his primary health care specialty. Black, Kenneth A can be contacted via phone (219) 759-1157.Contact Information
Primary practice address
3630 Willowcreek Rd
Portage IN 46368-5075
Phone: (219) 759-1157
Fax:
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Family Medicine | 207Q00000X | 01024841 | Indiana |
Profile Details
| NPI number | 1134184112 |
|---|---|
| LBN Legal business name | Black, Kenneth A |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Apr 20th, 2006 |
| Last updated | Feb 15th, 2008 - about 17 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1134184112 | NPPES |
| Indiana | MEDICAID | 100207860A | |
| Indiana | Other | 000000521738 | |
| Indiana | Other | 5251392 |
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