Basic Information
| Provider Information | |||||||||
| NPI: | 1699745562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CIVELLO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2225260001 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HENNESSY BLVD | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257673900 | ||||||||
| FaxNumber: | 2257662226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 201354 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 35084798 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 35084798 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 201354 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 1006122 | 01 | OH | QUAL | OTHER | 1108910 | 05 | LA | MEDICAID | 114845 | 01 | OH | KAISER | OTHER | E84798 | 01 | OH | SUMMA | OTHER | 000000364128 | 01 | OH | ANTHEM | OTHER | P00225594 | 01 | RAILROAD MEDICARE | OTHER | 2515157 | 05 | OH | MEDICAID |