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General NPI Number Information
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NPI Number | 1669479846
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Entity Type | Individual
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Provider Name | KENNETH TUCKER MD
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Gender | Male
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Dates
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Enumeration Date | 07/05/2005
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Last Update Date | 02/16/2015
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Provider Practice Location Address
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Address Line | 11900 E 12 MILE RD SUITE 300
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City | WARREN
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State | MI
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Zip | 48093-3400
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Country | US
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Telephone | 586-751-2072
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Fax | 586-751-1302
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Provider Business Mailing Address
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Address Line | 11900 E 12 MILE RD SUITE 300
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City | WARREN
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State | MI
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Zip | 48093-3400
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Country | US
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Telephone | 586-751-2072
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Fax | 586-751-1302
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 4301024231
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License Number State | MI
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