Provider Demographics
NPI:1467413047
Name:HARGROVE, KENNETH R (M D)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1661
Practice Address - Country:US
Practice Address - Phone:270-825-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000475396OtherBCBS PIN - CHS, INC.
KY6423585600Medicaid
KYP01367929OtherRAILROAD MEDICARE
KY6423585600Medicaid
KYP01367929OtherRAILROAD MEDICARE
KYK133401Medicare PIN
KY000000475396OtherBCBS PIN - CHS, INC.
KYD49575Medicare UPIN