Basic Information
| Provider Information | |||||||||
| NPI: | 1528061447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMMON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963314 | ||||||||
| FaxNumber: | 5742963351 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S NAPPANEE ST | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963314 | ||||||||
| FaxNumber: | 5742963351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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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 | 207RP1001X | 01029946A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | 01029946A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | 01029946A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 01029946A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100112420A | 05 | IN | MEDICAID |