Provider Demographics
NPI:1891742706
Name:MIDDLEBROOKS, KENNETH MARK (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARK
Last Name:MIDDLEBROOKS
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 1:100 PILOT MEDICAL DRIVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3430
Mailing Address - Country:US
Mailing Address - Phone:205-380-0848
Mailing Address - Fax:
Practice Address - Street 1:100 PILOT MEDICAL DRIVE
Practice Address - Street 2:SUITE 125
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3430
Practice Address - Country:US
Practice Address - Phone:205-380-0848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13413207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000089762Medicaid
AL631084624OtherTAX ID
AL000089762Medicaid
AL000089762Medicare PIN