Active NPI
Kenneth E Dudley, MD
- Family Medicine Physician
- Grand Rapids, MI
National Provider Identifier
1891727244
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 4301043631
- Practice address
- 1787 Grand Ridge CT NE
Suite 101
Grand Rapids, MI 49525 - Phone
- (616) 774-8131
- Fax
- (616) 774-8204
- NPI assigned
- Jul 7, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 4301043631 | MI | Primary |
Addresses
Primary practice location
1787 Grand Ridge CT NE
Suite 101
Grand Rapids, MI 49525
Mailing address
1787 Grand Ridge CT NE
Suite 101
Grand Rapids, MI 49525
Phone (616) 774-8131
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0004553974 | Other | MI | AETNA |
| 900000696 | Other | MI | PRIORITY HEALTH |
| 0D17690 | Other | MI | BLUE CROSS BLUE SHIELD |
| 2957039 | Medicaid | MI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152230400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1228262400000",
"number": "1891727244",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1787 GRAND RIDGE CT NE",
"address_2": "SUITE 101",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49525",
"telephone_number": "616-774-8131",
"fax_number": "616-774-8204"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1787 GRAND RIDGE CT NE",
"address_2": "SUITE 101",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "49525",
"telephone_number": "616-774-8131",
"fax_number": "616-774-8204"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DUDLEY",
"first_name": "KENNETH",
"middle_name": "E",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-07",
"last_updated": "2008-12-03",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MI",
"license": "4301043631",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "0004553974",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PRIORITY HEALTH",
"identifier": "900000696",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "0D17690",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2957039",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.