MEDICARE: MR. KENNETH R DODGE RPAC

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	363A00000X	Physician Assistant	0001001	NY
2	363AM0700X	Medical Physician Assistant	0001001	NY

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

General Provider Information

NPI Number	:	1952366601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH R DODGE RPAC

Provider Business Mailing Address
First Line	:	PO BOX 2340
Second Line	:
City	:	SOUTHAMPTON
State	:	NY
Zip	:	11969-2340
Country	:	US
Telephone Number	:	631-283-2100
Fax Number	:	631-283-5731

Provider Business Practice Location Address
First Line	:	200 PANTIAGO PLACE
Second Line	:	STE J
City	:	EAST HAMPTON
State	:	NY
Zip	:	11937
Country	:	US
Telephone Number	:	631-324-7700
Fax Number	:	631-324-7701

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

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	04/12/2008

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