1710115175 NPI number — SJL PHYSICIAN MANAGEMENT SERVICES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710115175 NPI number — SJL PHYSICIAN MANAGEMENT SERVICES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SJL PHYSICIAN MANAGEMENT SERVICES 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:
DBA PREMIER HEART AND VASCULAR CENTERS
Provider Other Organization Name Type Code:
3
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:
1710115175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-864-4040
Provider Business Mailing Address Fax Number:
606-877-1722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-2112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-864-4040
Provider Business Practice Location Address Fax Number:
606-864-3500
Provider Enumeration Date:
06/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CARMEL
Authorized Official Middle Name:
Authorized Official Title or Position:
VP REVENUE CYCLE & BUSINESS SERVICE
Authorized Official Telephone Number:
606-877-3918

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , 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: C21207 . This is a "CHI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000638615 . This is a "ANTHEM BCBS PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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