MEDICARE: KENNETH LEWIS WILLIAMS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	3091473-1205	UT

General Provider Information

NPI Number	:	1023091931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH LEWIS WILLIAMS M.D.

Provider Business Mailing Address
First Line	:	476 WILLIAMS WAY STE A
Second Line	:	PO BOX 1270
City	:	MOAB
State	:	UT
Zip	:	84532-2065
Country	:	US
Telephone Number	:	435-259-7121
Fax Number	:	435-259-3112

Provider Business Practice Location Address
First Line	:	476 WILLIAMS WAY
Second Line	:	STE A
City	:	MOAB
State	:	UT
Zip	:	84532-2065
Country	:	US
Telephone Number	:	435-259-7121
Fax Number	:	435-259-3112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	12/19/2011

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