Basic Information
| Provider Information | |||||||||
| NPI: | 1275517179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERKENBOSCH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 909 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402010909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026296000 | ||||||||
| FaxNumber: | 5026295865 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026296000 | ||||||||
| FaxNumber: | 5026295865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 38590 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 208000000X | 38590 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 38590 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64090947 | 05 | KY | MEDICAID | 200493520 | 05 | IN | MEDICAID |