1053485417 NPI number — CARITAS PHYSICIAN GROUP, INC.

Table of content: (NPI 1053485417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053485417 NPI number — CARITAS PHYSICIAN GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARITAS PHYSICIAN GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053485417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6801 DIXIE HWY
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40258-3913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-479-1400
Provider Business Mailing Address Fax Number:
502-479-1409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE 134
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40258-3913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-937-5888
Provider Business Practice Location Address Fax Number:
502-937-1237
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHING
Authorized Official First Name:
LOREE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE DIRECTOR
Authorized Official Telephone Number:
502-479-1403

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000065193 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2442685000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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