Provider Demographics
NPI:1093762148
Name:HOLBERT, KENNETH L (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:HOLBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1559 SPARTA ST
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1316
Practice Address - Country:US
Practice Address - Phone:931-815-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21847207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00297030OtherMEDICARE RAILROAD
TNP00259801OtherMEDICARE RAILROAD
TN3073134Medicaid
TN3051807OtherBLUE CROSS
TN3062431OtherBLUE CROSS
TN37513OtherTLC TENNCARE
TN532950OtherOMNICARE TENNCARE
TN3045786OtherBLUE CROSS
TN5001148OtherTLC TENNCARE
TN3333055Medicaid
TN3073132Medicaid
TN3045786OtherBLUE CROSS
TN532950OtherOMNICARE TENNCARE
TN3333055Medicaid
TN3073134Medicare PIN