Provider Demographics
NPI:1396705885
Name:BURNHAM, KENNETH SCOTT (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6896 W SNOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-7284207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH727173OtherBCHP
OH000000372947OtherANTHEM
OH341960760028OtherCARESOURCE
MI4433727Medicaid
OH000000271429OtherANTHEM
OH2181099Medicaid
OH810547599033Medicaid
MI000000372947Medicaid
OH2181099Medicaid
OHP00206956Medicare PIN
OHBU4014518Medicare ID - Type Unspecified
OH810547599033Medicaid
OH930120181Medicare PIN