Basic Information
Provider Information | |||||||||
NPI: | 1366434375 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TURK | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1601 BRIGHAM DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 435517114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198727700 | ||||||||
FaxNumber: | 4198740196 | ||||||||
Practice Location | |||||||||
Address1: | 1601 BRIGHAM DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 435517114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198727700 | ||||||||
FaxNumber: | 4198740196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35078516 | OH | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 000000141212 | 01 | OH | ANTHEM | OTHER | 2188672 | 05 | OH |   | MEDICAID | 2428937 | 01 | OH | AETNA | OTHER | 12-88038 | 01 | OH | UHC | OTHER | 03792 | 01 | OH | PHC | OTHER |