Provider Demographics
NPI:1346246873
Name:RICHMOND, KENNETH HERBERT (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:HERBERT
Last Name:RICHMOND
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 950116
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0116
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:502-213-3884
Practice Address - Street 1:3515 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1009
Practice Address - Country:US
Practice Address - Phone:502-459-3760
Practice Address - Fax:502-459-3717
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
KY24518207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64245186Medicaid
KY000000045107OtherBCBS
KY000000045107OtherBCBS
KY64245186Medicaid
KY64245186Medicaid
IN27-0810245OtherTIN