Provider Demographics
NPI:1114912987
Name:BECKLEY, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BECKLEY
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 1:8935 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5379
Mailing Address - Country:US
Mailing Address - Phone:317-564-2132
Mailing Address - Fax:317-574-4737
Practice Address - Street 1:8330 NAAB RD
Practice Address - Street 2:SUITE 234
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5925
Practice Address - Country:US
Practice Address - Phone:317-875-0084
Practice Address - Fax:317-876-5580
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01028542A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100368000Medicaid
IN100368000Medicaid
D95606Medicare UPIN
IN390002689Medicare PIN