Basic Information
| Provider Information | |||||||||
| NPI: | 1316903073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W CRESCENT PARK | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163652111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147234973 | ||||||||
| FaxNumber: | 8147238952 | ||||||||
| Practice Location | |||||||||
| Address1: | 143 PLEASANT DR | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147263310 | ||||||||
| FaxNumber: | 8177260295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD029673E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 25212101 | 01 | UNIERA | OTHER | 118477 | 01 | PA | BS | OTHER | 000972635 | 05 | PA | MEDICAID | 080103633 | 01 | PALMETTO | OTHER | 110565 | 01 | PA | MED PLUS | OTHER |