1194451179 NPI number — COMMUNITY MEDICAL ASSOCIATES, INC.

Table of content: (NPI 1194451179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194451179 NPI number — COMMUNITY MEDICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MEDICAL ASSOCIATES, 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:
1194451179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-558-9490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4803 OLYMPIA PARK PLZ STE 1100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40241-3068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-559-9409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAST
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP MANAGED CARE
Authorized Official Telephone Number:
502-272-5335

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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