MEDICARE: KENNETH JOHN SUPPES OD

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	152W00000X	Optometrist	4901002383	MI

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

General Provider Information

NPI Number	:	1972617355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH JOHN SUPPES OD

Provider Business Mailing Address
First Line	:	1885 N CENTER RD
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48638-5565
Country	:	US
Telephone Number	:	989-792-6627
Fax Number	:

Provider Business Practice Location Address
First Line	:	1885 N CENTER RD
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48638-5565
Country	:	US
Telephone Number	:	989-792-6627
Fax Number	:

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/08/2007

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