Basic Information
| Provider Information | |||||||||
| NPI: | 1588697718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARADA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419 | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497210419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316275601 | ||||||||
| FaxNumber: | 2316271471 | ||||||||
| Practice Location | |||||||||
| Address1: | 748 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497212220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316275601 | ||||||||
| FaxNumber: | 2316271471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 4301050538 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2933627 | 05 | MI | MEDICAID | 0801600151 | 01 | MI | INDIVIDUAL BLUE CROSS | OTHER |