Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RA0401X | Internist - Addiction Medicine | R2958 | KY |
Y | 207X00000X | Orthopaedic Surgeon | 50338 | KY |
N | 207X00000X | Orthopaedic Surgeon | R2958 | KY |
NPI | 1265708168 |
---|---|
Provider Name | Dr. Shane Jacob Kibbe |
First Address | Louisville, KY 40204-2061 |
Second Address | Louisville, KY 40204-2061 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2012 |
Last Update Date | 12/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01080524A | LICENSE (01) | IN |