1417066424 NPI number — BURKESVILLE MEDICAL SUPPLY, INC

Table of content: (NPI 1780658252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417066424 NPI number — BURKESVILLE MEDICAL SUPPLY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURKESVILLE MEDICAL SUPPLY, 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:
1417066424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42717-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-864-2230
Provider Business Mailing Address Fax Number:
270-864-2691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 KEEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURKESVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42717-0006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-864-2230
Provider Business Practice Location Address Fax Number:
270-864-2691
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER CEO
Authorized Official Telephone Number:
270-864-2230

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: MG0187 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000070347 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 006895400 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100164320 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90040296 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45906005 . This is a "ESPDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100165970 . This is a "ESDPT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".