Basic Information
| Provider Information | |||||||||
| NPI: | 1619066545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEPHART | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DELAWARE ST SE | ||||||||
| Address2: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123330770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2615 EAST FRANKLIN AVENUE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123330770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207QG0300X | 26265 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 032003 | 01 | MN | FAIRVEW | OTHER | 01-04725 | 01 | MN | MEDICA-PRIMARY | OTHER | 01-04725 | 01 | MN | MEDICA-CHOICE | OTHER | 32G78KE | 01 | MN | BCBS | OTHER | 100544 | 01 | MN | U CARE | OTHER | 934694 | 01 | ARAZID | OTHER | HP16524 | 01 | MN | HEALTH PARTNERS | OTHER | 0628004 | 01 | MN | PREFERRED ONE | OTHER |