1023016607 NPI number — DR. KENNETH BYERLY D.O.

Table of content: DR. KENNETH BYERLY D.O. (NPI 1023016607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023016607 NPI number — DR. KENNETH BYERLY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BYERLY
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023016607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3630 GUION RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46222-1616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-920-7195
Provider Business Mailing Address Fax Number:
317-920-7551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 GUION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46222-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-920-7195
Provider Business Practice Location Address Fax Number:
317-920-7551
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  02001355 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 146L00000X , with the licence number: 02001355 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000191757 . This is a "ANTHEM BLUE CROSS PROV. #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 2867358 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100270690A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02001355 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100386410 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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