1336126515 NPI number — DR. JAMES E MCKIERNAN MD

Table of content: DR. JAMES E MCKIERNAN MD (NPI 1336126515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336126515 NPI number — DR. JAMES E MCKIERNAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKIERNAN
Provider First Name:
JAMES
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1336126515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 950248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40295-0248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-238-2801
Provider Business Mailing Address Fax Number:
502-238-2835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 KRESGE WAY
Provider Second Line Business Practice Location Address:
SUITE 56
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-895-7265
Provider Business Practice Location Address Fax Number:
502-897-2113
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  18531 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0402X , with the licence number: 18531 , 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: 64185317 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2432390000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1049109 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100373820 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00719572 . This is a "RAILTOAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000617819 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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