MEDICARE: COLON & RECTAL SURGERY, LTD.

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	208C00000X	Colon & Rectal Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	32129	OTHER	PA	KEYSTONE MERCY HEALTH PLA
3	0091202000	OTHER	PA	INDEPENDENCE BLUE CROSS
4	CF6297	OTHER	GA	PALMETTO GBA
5	190824	OTHER	PA	HIGHMARK BLUE SHIELD

General Provider Information

NPI Number	:	1659390698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLON & RECTAL SURGERY, LTD.

Provider Business Mailing Address
First Line	:	1088 W BALTIMORE PIKE
Second Line	:	SUITE 2101
City	:	MEDIA
State	:	PA
Zip	:	19063-5136
Country	:	US
Telephone Number	:	610-565-3435
Fax Number	:	610-566-1387

Provider Business Practice Location Address
First Line	:	1088 W BALTIMORE PIKE
Second Line	:	SUITE 2101
City	:	MEDIA
State	:	PA
Zip	:	19063-5136
Country	:	US
Telephone Number	:	610-565-3435
Fax Number	:	610-566-1387

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH J BOYD
Credential	:	M.D.
Telephone Number	:	610-565-3435

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	12/14/2010

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Directions to “COLON & RECTAL SURGERY, LTD. ” Practice Location

Language	Start Address	Practice Location

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