Basic Information
| Provider Information | |||||||||
| NPI: | 1811958564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOWLES | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4453 CASTOR AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191243846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157442266 | ||||||||
| FaxNumber: | 2157439247 | ||||||||
| Practice Location | |||||||||
| Address1: | 4453 CASTOR AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191243846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157442266 | ||||||||
| FaxNumber: | 2157439247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 207RN0300X | OS006957E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0014065100001 | 05 | PA | MEDICAID | 1811958564 | 01 | PA | NPI | OTHER |