MEDICARE: KENNETH H PRUSHIK M.D.

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	208000000X	Pediatrics Physician	2018-00935	NC
2	2080A0000X	Pediatric Adolescent Medicine Physician	228253-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0600898	OTHER	NY	GHI
2	556Y51	OTHER	NY	BLUE CROSS/ BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	3C3318	OTHER	NY	HEALTHNET
5	P2939540	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1740290162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH H PRUSHIK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1994 WELLNESS BLVD STE 110
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-7768
Country	:	US
Telephone Number	:	704-384-8460
Fax Number	:

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	08/31/2023

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Directions to “ KENNETH H PRUSHIK M.D.” Practice Location

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