NPIMap

Individual provider Active NPI

Kenneth A. Widom, M.D.

  • Surgery Physician
  • Danville, PA
National Provider Identifier
1497706154
Registry record updated Jul 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
MD424958 Issued in PA
Practice address
100 N Academy Ave
Danville, PA 17822-2018
Phone
(570) 271-7149
NPI assigned
May 15, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery Physician 208600000X MD424958 PA Primary

Addresses

Primary practice location

100 N Academy Ave
Danville, PA 17822-2018

Mailing address

100 N Academy Ave
Danville, PA 17822-3034
Phone (570) 271-6144

Other identifiers 1

IdentifierTypeStateIssuer
101032558MedicaidPA

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address kwidom81545@direct.geisinger.edu Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040831000052 PA Practitioner - General Surgery 6709851066 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
General Surgery
Education
University of Maryland School of Medicine, 1998
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Geisinger ClinicGroup PAC ID 5395657001, 3,432 clinicians

Practice addresses (Care Compare)

100 N Academy Ave
Danville, PA 17822-9800
Phone (570) 271-6541

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Hernia repair - groin (open)1-10
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Geisinger Clinic CurrentSince Aug 1, 2004 Accepting new patients
Geisinger Clinic Current Accepting new patients
Geisinger Clinic CurrentSince Aug 1, 2004 Accepting new patients
Geisinger Clinic Past Accepting new patients
Geisinger Medical Center Past Accepting new patients

Locations

439 E 1st St
Bloomsburg, PA 17815
Phone (570) 387-1444

503 N 21st St
Camp Hill, PA 17011
Phone (717) 763-2100

100 N Academy Ave
Danville, PA 17822

Interoperability endpoints

  • Direct secure messaging: kwidom81545@direct.geisinger.edu

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 41

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 41

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1594857600000",
    "number": "1497706154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 N ACADEMY AVE",
            "city": "DANVILLE",
            "state": "PA",
            "postal_code": "178223034",
            "telephone_number": "570-271-6144",
            "fax_number": "570-271-6578"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 N ACADEMY AVE",
            "city": "DANVILLE",
            "state": "PA",
            "postal_code": "178222018",
            "telephone_number": "570-271-7149"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDOM",
        "first_name": "KENNETH",
        "middle_name": "A.",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-15",
        "last_updated": "2020-07-16",
        "certification_date": "2020-07-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "PA",
            "license": "MD424958",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "101032558",
            "state": "PA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kwidom81545@direct.geisinger.edu",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "100 N Academy Ave",
            "city": "Danville",
            "state": "PA",
            "country_code": "US",
            "postal_code": "178222018",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Danville, PA

Sources for this page

Verify at the official NPI Registry.