Provider Demographics
NPI:1831155167
Name:GLAVAN, KENNETH A (MD PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:GLAVAN
Suffix:
Gender:M
Credentials:MD PHD
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:859-578-5880
Mailing Address - Fax:859-578-5881
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:STE 132
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-578-5880
Practice Address - Fax:859-578-5881
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079176G208600000X
KY28334208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64283344Medicaid
OH2548256Medicaid
E96094Medicare UPIN
OH2548256Medicaid
KY64283344Medicaid
KY0957602Medicare PIN
KY0364991Medicare PIN
KY0957502Medicare PIN