Basic Information
| Provider Information | |||||||||
| NPI: | 1033270723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH O ANAEME LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11773 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852480013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809077707 | ||||||||
| FaxNumber: | 4809077097 | ||||||||
| Practice Location | |||||||||
| Address1: | 7615 W THUNDERBIRD RD STE 106 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235476838 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANAEME | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6026895820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | 30256 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | 208000000X | 30256 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 30256 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 324464 | 05 | AZ | MEDICAID |