=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306487525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH J GUTH MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2019
-----------------------------------------------------
Last Update Date | 09/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CENTRE DR STE G
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-740-1700
-----------------------------------------------------
Fax | 855-879-6594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 CENTRE DR STE G
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-4117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-740-1700
-----------------------------------------------------
Fax | 855-879-6594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | KENNETH J GUTH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 716-807-4264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------