Healthcare Provider Details

I. General information

NPI: 1609806546
Provider Name (Legal Business Name): KENNETH ALAN CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 2ND AVE S STE 270
BIRMINGHAM AL
35233-2900
US

IV. Provider business mailing address

255 W MICHIGAN AVE
JACKSON MI
49201-2218
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-7143
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number00017328
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: