Healthcare Provider Details

I. General information

NPI: 1144281163
Provider Name (Legal Business Name): KENNETH C NIEBERG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 DE LONGPRE AVE
HOLLYWOOD CA
90028-8253
US

IV. Provider business mailing address

PO BOX 10076
VAN NUYS CA
91410-0076
US

V. Phone/Fax

Practice location:
  • Phone: 323-462-2271
  • Fax:
Mailing address:
  • Phone: 805-578-8300
  • Fax: 805-578-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH C NIEBERG
Title or Position: PRESIDENT
Credential: MD
Phone: 323-462-2271