Healthcare Provider Details

I. General information

NPI: 1275637951
Provider Name (Legal Business Name): KENNETH K GREENWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 PONDELLA RD COASTAL BEHAVIORAL HEALTHCARE
NORTH FORT MYERS FL
33903-3532
US

IV. Provider business mailing address

951 PONDELLA RD COASTAL BEHAVIORAL HEALTHCARE
NORTH FORT MYERS FL
33903-3532
US

V. Phone/Fax

Practice location:
  • Phone: 239-656-3461
  • Fax: 239-656-3462
Mailing address:
  • Phone: 239-656-3461
  • Fax: 239-656-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number29687
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: