Basic Information
Provider Information | |||||||||
NPI: | 1457302564 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKER | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3276 | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477313276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124911307 | ||||||||
FaxNumber: | 8124735822 | ||||||||
Practice Location | |||||||||
Address1: | 1116 MILLIS AVE | ||||||||
Address2: |   | ||||||||
City: | BOONVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 476012204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124730181 | ||||||||
FaxNumber: | 8124735822 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2006 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01037962A | IN | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 01037962A | IN | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 100334280 | 05 | IN |   | MEDICAID | 64872856 | 05 | KY |   | MEDICAID | 000000042725 | 01 | IN | BLUE SHIELD | OTHER | 050052833 | 01 |   | RAILROAD MEDICARE | OTHER |