Provider Demographics
NPI:1528055076
Name:PICKOVER, KENNETH HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HOWARD
Last Name:PICKOVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3415
Mailing Address - Country:US
Mailing Address - Phone:718-556-3900
Mailing Address - Fax:
Practice Address - Street 1:59 REVERE ST
Practice Address - Street 2:SUITE A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3415
Practice Address - Country:US
Practice Address - Phone:718-556-3900
Practice Address - Fax:718-273-3592
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164175207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01087645Medicaid
NY28E101Medicare ID - Type Unspecified
NY01087645Medicaid