Provider Demographics
NPI:1245293034
Name:KENNEBECK, GREG (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:KENNEBECK
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 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5501
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:STE. 6000
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-7880
Practice Address - Fax:513-475-8766
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080848K207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2308461Medicaid
IN200376210Medicaid
KY64049067Medicaid
H32380Medicare UPIN
KY64049067Medicaid