1194711150 NPI number — DR. BARRY L DICK MD

Table of content: DR. BARRY L DICK MD (NPI 1194711150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194711150 NPI number — DR. BARRY L DICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICK
Provider First Name:
BARRY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1194711150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 CHAMBER CENTER DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAKESIDE PARK
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017-1673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-344-5555
Provider Business Mailing Address Fax Number:
859-344-5552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 S LOOP RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-3415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-344-1600
Provider Business Practice Location Address Fax Number:
859-344-0091
Provider Enumeration Date:
09/26/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  29604 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 29604 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 29604 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7100056850 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100354170 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01058472 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 0915148 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00252704 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64933096 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".