Provider Demographics
NPI:1053426395
Name:FALLON, KENNETH B (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:FALLON
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:619 19TH ST S
Mailing Address - Street 2:P210 WEST PAVILION-UAB DEPARTMENT OF PATHOLOGY
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1900
Mailing Address - Country:US
Mailing Address - Phone:205-934-2164
Mailing Address - Fax:205-975-7548
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:P210 WEST PAVILION-UAB DEPARTMENT OF PATHOLOGY
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1900
Practice Address - Country:US
Practice Address - Phone:205-934-2164
Practice Address - Fax:205-975-7548
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV22385207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00354856OtherRAILROAD MEDICARE
WV3810005914Medicaid
WVP00354856OtherRAILROAD MEDICARE
WVFA6034681Medicare PIN