Provider Demographics
NPI:1316937873
Name:CERVONE, KENNETH R (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:CERVONE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:24715 LITTLE MACK AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:586-779-7970
Mailing Address - Fax:586-779-7748
Practice Address - Street 1:24715 LITTLE MACK
Practice Address - Street 2:STE 100
Practice Address - City:ST CLAIR SHORE
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-779-7970
Practice Address - Fax:586-779-7748
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2014-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301058405207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3250375Medicaid
G24274Medicare UPIN