1447573076 NPI number — ALBERTO RENE MALDONADO, M.D., P.S.C.

Table of content: (NPI 1447573076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447573076 NPI number — ALBERTO RENE MALDONADO, M.D., P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBERTO RENE MALDONADO, M.D., P.S.C.
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:
1447573076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 EASTERN PKWY
Provider Second Line Business Mailing Address:
SUITE 3337
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40217-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-456-9214
Provider Business Mailing Address Fax Number:
502-458-9348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 EASTERN PKWY
Provider Second Line Business Practice Location Address:
SUITE 3337
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-456-9214
Provider Business Practice Location Address Fax Number:
502-458-9348
Provider Enumeration Date:
03/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MALDONADO
Authorized Official First Name:
ALBERTO
Authorized Official Middle Name:
RENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
502-456-9214

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  21106 , 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: 000000049333 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 240007602 . This is a "PALMETTOGBA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2432718000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: K005255 . This is a "CHAMPUS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100014410A . This is a "MEDICAID OF INDIANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64211063 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1049929 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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