Basic Information
Provider Information | |||||||||
NPI: | 1245443068 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIU | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIU | ||||||||
OtherFirstName: | KENNETH | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 100 N ACADEMY AVE | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 178224903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5702716144 | ||||||||
FaxNumber: | 5702716578 | ||||||||
Practice Location | |||||||||
Address1: | 1000 E MOUNTAIN BLVD | ||||||||
Address2: |   | ||||||||
City: | WILKES BARRE | ||||||||
State: | PA | ||||||||
PostalCode: | 187110027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708086026 | ||||||||
FaxNumber: | 5708083298 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD28211 | OR | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 0101247845 | VA | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | MD462610 | PA | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
No ID Information.