MEDICARE: KENNETH S LARSEN MD

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	207V00000X	Obstetrics & Gynecology Physician	932612681205	UT

General Provider Information

NPI Number	:	1588767081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH S LARSEN MD

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-501-5590
Fax Number	:

Provider Business Practice Location Address
First Line	:	9600 S 1300 E
Second Line	:	#308
City	:	SANDY
State	:	UT
Zip	:	84094-3766
Country	:	US
Telephone Number	:	801-501-5590
Fax Number	:

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

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	10/20/2007

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Directions to “ KENNETH S LARSEN MD” Practice Location

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