Healthcare Provider Details

I. General information

NPI: 1871728451
Provider Name (Legal Business Name): PHILIP JOHN KALLENBERG M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF KENTUCKY & AFFILIATES 800 ROSE ST.
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

2160 FONTAINE RD APT 345
LEXINGTON KY
40502-1345
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-1000
  • Fax:
Mailing address:
  • Phone: 859-317-9920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: