Provider Demographics
NPI:1568434843
Name:KING, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:KING
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 1:500 GEORGE MCCLAIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025
Mailing Address - Country:US
Mailing Address - Phone:270-527-8626
Mailing Address - Fax:
Practice Address - Street 1:500 GEORGE MCCLAIN DRIVE
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025
Practice Address - Country:US
Practice Address - Phone:270-527-8626
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17956207R00000X
TN8778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000198973OtherBLUE CROSS BLUE SHIELD
1500OtherBCBS FEDERAL
KY64179567Medicaid
1500OtherBCBS FEDERAL
1168901Medicare ID - Type Unspecified