MEDICARE: KENNETH C NIEBERG MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZC0500X	Cytopathology Physician
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801857834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH C NIEBERG MD INC

Provider Business Mailing Address
First Line	:	PO BOX 10076
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91410-0076
Country	:	US
Telephone Number	:	805-578-8300
Fax Number	:	805-578-8950

Provider Business Practice Location Address
First Line	:	4081 E OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-3330
Country	:	US
Telephone Number	:	323-267-0477
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH C NIEBERG
Credential	:	MD
Telephone Number	:	323-267-0477

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	06/01/2010

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