Healthcare Provider Details

I. General information

NPI: 1003910118
Provider Name (Legal Business Name): KENNETH GWINN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48681 HAYES RD
SHELBY TOWNSHIP MI
48315-4403
US

IV. Provider business mailing address

48681 HAYES RD
SHELBY TOWNSHIP MI
48315-4403
US

V. Phone/Fax

Practice location:
  • Phone: 586-799-1212
  • Fax: 586-799-1210
Mailing address:
  • Phone: 586-799-1212
  • Fax: 586-799-1210

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:
Title or Position:
Credential:
Phone: