Provider Demographics
NPI:1760657027
Name:KENNETH C HUBER, MD, LTD
Entity Type:Organization
Organization Name:KENNETH C HUBER, MD, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-935-6633
Mailing Address - Street 1:11676 PERRY HWY
Mailing Address - Street 2:SUITE 1304
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7201
Mailing Address - Country:US
Mailing Address - Phone:724-935-6633
Mailing Address - Fax:724-935-2600
Practice Address - Street 1:11676 PERRY HWY
Practice Address - Street 2:SUITE 1304
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-7201
Practice Address - Country:US
Practice Address - Phone:724-935-6633
Practice Address - Fax:724-935-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA038716E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011105620005Medicaid
PA757916Medicare PIN
PA0011105620005Medicaid