Basic Information
| Provider Information | |||||||||
| NPI: | 1669465423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEBERLING | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | ST. ELIZABETH HEALTHCARE | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593447207 | ||||||||
| FaxNumber: | 8593445553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 39322 | KY | N | Other Service Providers | Specialist | 207R00000X | 39322 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35083786 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64107600 | 05 | KY | MEDICAID | 2594652 | 05 | OH | MEDICAID | 200977020 | 05 | IN | MEDICAID |