MEDICARE: KENNETH BAZYDLO

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	207Q00000X	Family Medicine Physician	TP195	KY
2	207Q00000X	Family Medicine Physician	MT215774	PA

General Provider Information

NPI Number	:	1558854174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH BAZYDLO

Provider Business Mailing Address
First Line	:	PO BOX 635283
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-5283
Country	:	US
Telephone Number	:	859-301-3800
Fax Number	:	859-301-3987

Provider Business Practice Location Address
First Line	:	413 SOUTH LOOP ROAD
Second Line	:
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-5446
Country	:	US
Telephone Number	:	859-301-3800
Fax Number	:	859-301-3987

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

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	01/12/2026

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Directions to “ KENNETH BAZYDLO ” Practice Location

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