Provider Demographics
NPI:1245468271
Name:KENNETH M LEVINE, D.O. LTD
Entity type:Organization
Organization Name:KENNETH M LEVINE, D.O. LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-838-9388
Mailing Address - Street 1:2121 S MILL AVE
Mailing Address - Street 2:114
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2138
Mailing Address - Country:US
Mailing Address - Phone:480-838-9388
Mailing Address - Fax:480-840-1393
Practice Address - Street 1:2121 S MILL AVE
Practice Address - Street 2:114
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2138
Practice Address - Country:US
Practice Address - Phone:480-838-9388
Practice Address - Fax:480-840-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1696207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE39804Medicare UPIN