MEDICARE: DR. KENNETH HENTSCHEL DO, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204R00000X	Electrodiagnostic Medicine Physician	OS8644	FL
2	2084N0400X	Neurology Physician	057817	GA
3	2084N0600X	Clinical Neurophysiology Physician	OS8644	FL
4	2084N0400X	Neurology Physician	OS8644	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164405460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH HENTSCHEL DO, PHD

Provider Business Mailing Address
First Line	:	3 SHIRCLIFF WAY
Second Line	:	SUITE 724
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4786
Country	:	US
Telephone Number	:	904-308-7959
Fax Number	:	904-308-7938

Provider Business Practice Location Address
First Line	:	4205 BELFORT RD STE 1100
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5876
Country	:	US
Telephone Number	:	904-450-6300
Fax Number	:	904-281-5866

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	07/29/2019

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