Provider Demographics
NPI:1619928058
Name:EBERT, KENNETH A (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:EBERT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S LAKE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6638
Mailing Address - Country:US
Mailing Address - Phone:219-947-6695
Mailing Address - Fax:219-947-6092
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-947-6695
Practice Address - Fax:219-947-6092
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28128216A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200097770Medicaid
IN200097770Medicaid