Basic Information
| Provider Information | |||||||||
| NPI: | 1497783161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEISS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052435512 | ||||||||
| FaxNumber: | 3052434613 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052435512 | ||||||||
| FaxNumber: | 3052434613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35-05-2264 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME86986 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2032017 | 05 | OH | MEDICAID | P01212498 | 01 | MS | RAILROAD MEDICARE | OTHER | 2591054 | 01 | OH | AETNA | OTHER | 64037559 | 05 | KY | MEDICAID | 3810002515 | 05 | WV | MEDICAID | 000000199157 | 01 | OH | ANTHEM | OTHER | 200343060 | 05 | IN | MEDICAID |