Basic Information
| Provider Information | |||||||||
| NPI: | 1366407934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCCINO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E. MAIN STREET, SUITE C | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975016041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894728 | ||||||||
| FaxNumber: | 5417894765 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E. MAIN STREET, SUITE C | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975016041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894728 | ||||||||
| FaxNumber: | 5417894765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| 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 | 207PE0004X | MD21074 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 151255 | 05 | OR | MEDICAID |