Provider Demographics
NPI:1457302564
Name:PARKER, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:PARKER
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 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-491-1307
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:1116 MILLIS AVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2204
Practice Address - Country:US
Practice Address - Phone:812-473-0181
Practice Address - Fax:812-473-5822
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037962A207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100334280Medicaid
KY64872856Medicaid
IN000000042725OtherBLUE SHIELD
050052833OtherRAILROAD MEDICARE
IN000000042725OtherBLUE SHIELD
IN100334280Medicaid