Provider Demographics
NPI:1215958574
Name:BERENBOM, LOREN D (MD)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:D
Last Name:BERENBOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CAMBRIDGE ST STE G600
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8501
Mailing Address - Country:US
Mailing Address - Phone:913-588-9600
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST STE G600
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-9600
Practice Address - Fax:913-588-9770
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8581207RC0000X, 207RC0001X
KS04-19762207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
10337013OtherBCBS KC
KS100202580AMedicaid
KS051552OtherBCBS KS
MO202205407Medicaid
KS100202580BMedicaid
MO0386419EMedicare PIN
KS051552OtherBCBS KS
KS051552Medicare PIN
MO0386419AMedicare PIN
KS100202580BMedicaid
KS110330017Medicare PIN
10337013OtherBCBS KC
KS0386419BMedicare PIN
MO202205407Medicaid