Basic Information
| Provider Information | |||||||||
| NPI: | 1922150697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUIDERA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 209036 | ||||||||
| Address2: | SHRINERS HOSPITALS FOR CHILDREN TWIN CITIES | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753209036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818478 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 E RIVER PKWY | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125966187 | ||||||||
| FaxNumber: | 6123397634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 04/04/2011 | ||||||||
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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 | 207XP3100X | 47329 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 158417100 | 05 | MN | MEDICAID | 1922150697 | 05 | MN | MEDICAID |