Provider Demographics
NPI:1083623367
Name:GREEN, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1479
Mailing Address - Country:US
Mailing Address - Phone:270-259-1626
Mailing Address - Fax:270-259-9582
Practice Address - Street 1:1895 ELIZABETHTOWN RD
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-9138
Practice Address - Country:US
Practice Address - Phone:270-230-0182
Practice Address - Fax:270-230-0014
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1064549OtherPASSPORT HEALTH PLAN
KY2434453000OtherPASSPORT ADVANTAGE
KY64239247Medicaid
KY1064549OtherPASSPORT HEALTH PLAN
KY1407901Medicare PIN