Basic Information
| Provider Information | |||||||||
| NPI: | 1609843473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKODNEK | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE | ||||||||
| Address2: | MEDICAL STAFF OFFICE BOX 42 | ||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726511 | ||||||||
| FaxNumber: | 5165723210 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE | ||||||||
| Address2: | MEDICAL STAFF OFFICE BOX 42 | ||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726511 | ||||||||
| FaxNumber: | 5165723210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 104630 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00512827 | 05 | NY | MEDICAID |