Basic Information
| Provider Information | |||||||||
| NPI: | 1154387918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEARSEN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
| FaxNumber: | 7168364696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 181834 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04026003061 | 01 | FIDELIS | OTHER | 1818343B | 01 | NY | WORKERS COMPENSATION | OTHER | P020181834 | 01 | BLUE SHIELD ROCHESTER | OTHER | P010181834 | 01 | BLUE CHOICE | OTHER | 000911558015 | 01 | BLUE SHIELD WNY | OTHER | 01230148 | 05 | NY | MEDICAID | 000911558011 | 01 | BLUE SHIELD WNY | OTHER | 101326FF | 01 | PREFERRED CARE | OTHER | 00025335602 | 01 | UNIVERA | OTHER | 0142865 | 01 | GHI | OTHER | 4195929 | 01 | GHI | OTHER | 00025335605 | 01 | UNIVERA | OTHER | 1693149 | 01 | INDEPENDENT HEALTH | OTHER | P00005729 | 01 | RR MEDICARE | OTHER |