1881874592 NPI number — EASTERN KENTUCKY KIDNEY CARE, PSC

Table of content: (NPI 1881874592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881874592 NPI number — EASTERN KENTUCKY KIDNEY CARE, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN KENTUCKY KIDNEY CARE, PSC
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:
1881874592
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-437-0662
Provider Business Mailing Address Fax Number:
606-437-0618

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 WEDDINGTON BRANCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501-3204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-437-0662
Provider Business Practice Location Address Fax Number:
606-437-0618
Provider Enumeration Date:
11/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOSEPH
Authorized Official First Name:
KASSAW
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
606-437-0662

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  TP610 , 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: 1861453409 . This is a "PERSONAL NPI" identifier . This identifiers is of the category "OTHER".