Basic Information
| Provider Information | |||||||||
| NPI: | 1770525891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUDSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12502 WILLOWBROOK RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215026491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409648740 | ||||||||
| FaxNumber: | 2409648741 | ||||||||
| Practice Location | |||||||||
| Address1: | 12502 WILLOWBROOK RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215026491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2409648740 | ||||||||
| FaxNumber: | 2409648741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
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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 | 207RC0000X | OS010445L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | OS010445L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 2670622 | 05 | OH | MEDICAID | 2670622 | 05 | WV | MEDICAID | 0018530940003 | 05 | PA | MEDICAID |