1497740997 NPI number — BOWLING GREEN DIALYSIS CENTER INC

Table of content: (NPI 1497740997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497740997 NPI number — BOWLING GREEN DIALYSIS CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOWLING GREEN DIALYSIS CENTER 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:
RAJAN KARALAKULASINGAM BOWLING GREEN KIDNEY CENTER
Provider Other Organization Name Type Code:
4
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:
1497740997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4114 BROWNS LN
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:
40220-1534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-458-6359
Provider Business Mailing Address Fax Number:
502-459-8626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1834 LYDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42104-3361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-782-1318
Provider Business Practice Location Address Fax Number:
270-793-9558
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KARALAKULASINGAM
Authorized Official First Name:
RAJANTHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/DIRECTOR
Authorized Official Telephone Number:
502-458-6359

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  300032 , 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: 000000054740 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 39090048 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 610939927 . This is a "ALL OTHER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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