Basic Information
| Provider Information | |||||||||
| NPI: | 1295703122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855506 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN STREET | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5135583136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35 051087 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 35-051087 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 64786429 | 05 | KY | MEDICAID | P00442454 | 01 | RAILROAD MEDICARE | OTHER | 0571804 | 05 | OH | MEDICAID |