Healthcare Provider Details

I. General information

NPI: 1033395256
Provider Name (Legal Business Name): KENNETH W. KILGORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 COPPERFIELD CIR
LITITZ PA
17543-9482
US

IV. Provider business mailing address

46 COPPERFIELD CIR
LITITZ PA
17543-9482
US

V. Phone/Fax

Practice location:
  • Phone: 717-626-7666
  • Fax: 717-626-1605
Mailing address:
  • Phone: 717-626-7666
  • Fax: 717-626-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC004716L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier50007504
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS

VIII. Authorized Official

Name: DR. KENNETH W. KILGORE
Title or Position: OWNER/ PHYSICIAN
Credential: D.P.M.
Phone: 717-626-7666