1225452774 NPI number — KENTUCKIANA ANESTHESIOLOGY, PLLC

Table of content: (NPI 1225452774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225452774 NPI number — KENTUCKIANA ANESTHESIOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKIANA ANESTHESIOLOGY, PLLC
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:
MEDICAL ANESTHESIA PARTNERS
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:
1225452774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5516 WEATHERBY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-3417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-577-7635
Provider Business Mailing Address Fax Number:
972-612-5811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5516 WEATHERBY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-577-7635
Provider Business Practice Location Address Fax Number:
972-612-5811
Provider Enumeration Date:
02/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MCWHORTER
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-577-7635

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  J5406 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 148622704 . This is a "MEDICAID CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0062ZP . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 148622705 . This is a "MEDICAID CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8227M8 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 148622702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7788421 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 148622703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 148622701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 902840910 . This is a "UNIED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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