Provider Demographics
NPI:1821250622
Name:KENNETH J.S.DESIMONE.,M.D.,F.A.C.S.,P.L.L.C.
Entity Type:Organization
Organization Name:KENNETH J.S.DESIMONE.,M.D.,F.A.C.S.,P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JS
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-932-4203
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:42743-0180
Mailing Address - Country:US
Mailing Address - Phone:270-932-4203
Mailing Address - Fax:270-932-7019
Practice Address - Street 1:704 COLUMBIA HWY
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-1118
Practice Address - Country:US
Practice Address - Phone:270-932-4203
Practice Address - Fax:270-932-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11774208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64117740Medicaid
KY64117740Medicaid