Provider Demographics
NPI:1669465423
Name:HEBERLING, KENNETH T (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
Last Name:HEBERLING
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:ST. ELIZABETH HEALTHCARE
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-344-7207
Practice Address - Fax:859-344-5553
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39322174400000X, 207R00000X
OH35083786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64107600Medicaid
OH2594652Medicaid
IN200977020Medicaid
OHH012520Medicare PIN
KYP00238848Medicare PIN
IN200977020Medicaid
KY3400181Medicare PIN
KY64107600Medicaid
KYK026080Medicare PIN