Provider Demographics
NPI:1265423479
Name:KRZYZANIAK, KENNETH E (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:KRZYZANIAK
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:823 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-449-1010
Practice Address - Fax:843-497-6171
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD10499208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC771701OtherWELLCARE
NC890508MMedicaid
SCGP1418Medicaid
SCGP454522Medicaid
SC104997Medicaid
SC340011957OtherRAILROAD MEDICARE
SC80023039OtherSELECT HEALTH
SCP00360560OtherRAILROAD MEDICARE
SCB92346Medicare UPIN
SCGP1418Medicaid