Basic Information
| Provider Information | |||||||||
| NPI: | 1346294212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WLOCZEWSKI | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4647 TROXELL DR | ||||||||
| Address2: | |||||||||
| City: | WHITEHALL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180521441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105021288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 ROSEBERRY ST | ||||||||
| Address2: | |||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088651690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088596700 | ||||||||
| FaxNumber: | 9088596812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MB080271 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0063274 | 05 | NJ | MEDICAID |