Provider Demographics
NPI:1114071255
Name:EBERT, JOHN TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TIMOTHY
Last Name:EBERT
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 1313
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241
Mailing Address - Country:US
Mailing Address - Phone:270-889-0567
Mailing Address - Fax:270-889-9048
Practice Address - Street 1:105B WEST 18TH STREET
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240
Practice Address - Country:US
Practice Address - Phone:270-889-0567
Practice Address - Fax:270-889-9048
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY311142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64311145Medicaid
KY000000054212Medicaid
C92558Medicare UPIN
KY000000054212Medicaid