Basic Information
| Provider Information | |||||||||
| NPI: | 1811958150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 W ALAMEDA ST | ||||||||
| Address2: | 25 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059827321 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W ALAMEDA ST | ||||||||
| Address2: | 25 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059827321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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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 | 91-318 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 91-318 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000R7779 | 05 | NM | MEDICAID | 416182 | 05 | AZ | MEDICAID |