Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 011230 | LA |
NPI | 1033154968 |
---|---|
Provider Name | Dr. Kenneth Mciver Blue JR. |
First Address | Baton Rouge, LA 70810-7827 |
Second Address | Baton Rouge, LA 70810-7827 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2006 |
Last Update Date | 23/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
011230 | MEDICAL LICENSE (01) | LA |
1117609 | (05) | LA |
B60247 | (02) |