Healthcare Provider Details

I. General information

NPI: 1679665319
Provider Name (Legal Business Name): KENNETH JOHN PRICE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 E GRAND RIVER AVE SUITE 211
LANSING MI
48912-4300
US

IV. Provider business mailing address

PO BOX 13008
LANSING MI
48901-3008
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-8686
  • Fax: 517-364-8685
Mailing address:
  • Phone: 517-364-6253
  • Fax: 517-364-6204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010707
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: