Healthcare Provider Details

I. General information

NPI: 1629163217
Provider Name (Legal Business Name): KENNETH L GWINN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48681 HAYES RD
SHELBY TOWNSHIP MI
48315
US

IV. Provider business mailing address

1976 MOMENTUM PL
CHICAGO IL
60689-5319
US

V. Phone/Fax

Practice location:
  • Phone: 586-799-1212
  • Fax:
Mailing address:
  • Phone: 586-799-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberKG050974
License Number StateMI

VIII. Authorized Official

Name: DR. KENNETH L GWINN
Title or Position: PRESIDENT
Credential: MD
Phone: 586-799-1212