Basic Information
Provider Information
NPI: 1003803321
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TURNER
FirstName: KENNETH
MiddleName: B
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 1648
Address2:  
City: RUSSELLVILLE
State: AR
PostalCode: 728111648
CountryCode: US
TelephoneNumber: 4799687170
FaxNumber: 4799687607
Practice Location
Address1: 108 SKYLINE DR
Address2:  
City: RUSSELLVILLE
State: AR
PostalCode: 728013362
CountryCode: US
TelephoneNumber: 4799687170
FaxNumber: 4799687607
Other Information
ProviderEnumerationDate: 10/03/2005
LastUpdateDate: 12/10/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XC-6479ARY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
11748100105AR MEDICAID


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