Provider Demographics
NPI:1699744342
Name:MARNOCHA, KENNETH E (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:MARNOCHA
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8335
Practice Address - Street 1:253 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1501
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031076A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156682OtherPHCS PID NUMBER
IN10825542OtherCAQH NUMBER
IN000000202120OtherANTHEM PROVIDER NUMBER
IN100320630Medicaid
IN815510KKMedicare PIN
IN815500DDDDMedicare PIN
IN100320630Medicaid
IN815520NNMedicare PIN
IN870630TMedicare PIN
IN224390DMedicare PIN
IN10825542OtherCAQH NUMBER
IN300123686Medicare PIN
IN185510JJMedicare PIN
IN815460KKKMedicare PIN