Provider Demographics
NPI:1598778136
Name:GRAMYK, KENNETH JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:GRAMYK
Suffix:
Gender:
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:083-675-1702
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6051 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8969
Practice Address - Country:US
Practice Address - Phone:208-302-5150
Practice Address - Fax:208-302-5155
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6718207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003704700Medicaid