Provider Demographics
NPI:1194090308
Name:KENNETH E YAGODICH, MD, PC
Entity type:Organization
Organization Name:KENNETH E YAGODICH, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:YAGODICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-868-0800
Mailing Address - Street 1:1200 HEINLEIN RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47725-6379
Mailing Address - Country:US
Mailing Address - Phone:812-868-0800
Mailing Address - Fax:812-868-0804
Practice Address - Street 1:1200 HEINLEIN RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47725-6379
Practice Address - Country:US
Practice Address - Phone:812-868-0800
Practice Address - Fax:812-868-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1578604633OtherTYPE I NPI
INE76815Medicare UPIN
IN187030Medicare PIN