Basic Information
| Provider Information | |||||||||
| NPI: | 1366434268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNBECK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 JEFFERSON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192512032 | ||||||||
| FaxNumber: | 4192511485 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 W MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192264310 | ||||||||
| FaxNumber: | 4192264315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2006 | ||||||||
| NPIReactivationDate: | 03/28/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34005321 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0420471 | 01 | UHC | OTHER | 000000077070 | 01 | ANTHEM | OTHER | 0869074 | 05 | OH | MEDICAID |