Provider Demographics
NPI:1538383120
Name:PRIMM, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PRIMM
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 1:1710 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1033
Mailing Address - Country:US
Mailing Address - Phone:765-364-3151
Mailing Address - Fax:765-364-8517
Practice Address - Street 1:1710 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1033
Practice Address - Country:US
Practice Address - Phone:765-364-3151
Practice Address - Fax:765-364-8517
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060295A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200541670Medicaid
IN200541670Medicaid
IN228160XMedicare PIN