Provider Demographics
NPI:1154382083
Name:BLUE, KENNETH MCIVER III (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MCIVER
Last Name:BLUE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TREY
Other - Middle Name:
Other - Last Name:BLUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8080 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-766-8100
Mailing Address - Fax:225-408-6896
Practice Address - Street 1:8080 BLUEBONNET BLVD
Practice Address - Street 2:SUITE 3000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7827
Practice Address - Country:US
Practice Address - Phone:225-766-8100
Practice Address - Fax:225-408-6896
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL#TRN4689208800000X
LAMD.200727208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1502821Medicaid
LA4K235D690Medicare PIN
I60407Medicare UPIN