Healthcare Provider Details

I. General information

NPI: 1669465423
Provider Name (Legal Business Name): KENNETH T HEBERLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR ST. ELIZABETH HEALTHCARE
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-7207
  • Fax: 859-344-5553
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number39322
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number39322
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35083786
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: