Healthcare Provider Details

I. General information

NPI: 1366407934
Provider Name (Legal Business Name): KENNETH R BUCCINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E. MAIN STREET, SUITE C
MEDFORD OR
97501-6041
US

IV. Provider business mailing address

100 E. MAIN STREET, SUITE C
MEDFORD OR
97501-6041
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4728
  • Fax: 541-789-4765
Mailing address:
  • Phone: 541-789-4728
  • Fax: 541-789-4765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD21074
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier151255
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: