Provider Demographics
NPI:1023016607
Name:BYERLY, KENNETH (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:BYERLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 GUION RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1616
Mailing Address - Country:US
Mailing Address - Phone:317-920-7195
Mailing Address - Fax:317-920-7551
Practice Address - Street 1:3630 GUION RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1616
Practice Address - Country:US
Practice Address - Phone:317-920-7195
Practice Address - Fax:317-920-7551
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001355146L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000191757OtherANTHEM BLUE CROSS PROV. #
IN100270690AMedicaid
IN02001355OtherSTATE LICENSE NUMBER
IN100386410Medicaid
IN100270690AMedicaid
IN02001355OtherSTATE LICENSE NUMBER