Healthcare Provider Details

I. General information

NPI: 1699745562
Provider Name (Legal Business Name): KENNETH CHARLES CIVELLO JR. MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD SUITE 1000
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-3900
  • Fax: 225-766-2226
Mailing address:
  • Phone: 222-526-0001
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number201354
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35084798
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35084798
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number201354
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: