Basic Information
| Provider Information | |||||||||
| NPI: | 1760534655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 SCRANTON CARBONDALE HWY | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185081115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703434334 | ||||||||
| FaxNumber: | 5702074287 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 SCRANTON CARBONDALE HWY | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185081115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703434334 | ||||||||
| FaxNumber: | 5702074287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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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 | MD020994E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 001223833 | 05 | PA | MEDICAID |