Provider Demographics
NPI:1508802950
Name:GREEN, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-489-6613
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1025 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9154
Practice Address - Country:US
Practice Address - Phone:502-222-0598
Practice Address - Fax:502-222-7446
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY24940208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6424940200Medicaid
KY6424940200Medicaid
C70737Medicare UPIN