Provider Demographics
NPI:1679665319
Name:PRICE, KENNETH JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:PRICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:2909 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4300
Practice Address - Country:US
Practice Address - Phone:517-364-8686
Practice Address - Fax:517-364-8685
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0153300795OtherBCBS INDIVIDUAL PIN
MI2829520Medicaid
MIOC36170007Medicare ID - Type Unspecified
MI2829520Medicaid