MEDICARE: KENNETH CHARLES STUDYVIN D.O.

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	207P00000X	Emergency Medicine Physician	DOR5D51	MO

General Provider Information

NPI Number	:	1922041342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH CHARLES STUDYVIN D.O.

Provider Business Mailing Address
First Line	:	2620 NORTH WESTWOOD
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-9711
Country	:	US
Telephone Number	:	573-727-2567
Fax Number	:	573-727-2379

Provider Business Practice Location Address
First Line	:	2620 NORTH WESTWOOD
Second Line	:
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-9711
Country	:	US
Telephone Number	:	573-727-2567
Fax Number	:	573-727-2379

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/08/2007

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