1548273733 NPI number — DERMATOPATHOLOGY ALLIANCE OF KENTUCKY PLLC

Table of content: (NPI 1548273733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548273733 NPI number — DERMATOPATHOLOGY ALLIANCE OF KENTUCKY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATHOLOGY ALLIANCE OF KENTUCKY 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:
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:
1548273733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 BISHOP LN STE 1018
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:
40218-1928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-456-6217
Provider Business Mailing Address Fax Number:
502-456-4440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
839 S 2ND ST
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:
40203-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-456-6217
Provider Business Practice Location Address Fax Number:
502-456-4440
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEARNEYHOUGH
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PATHOLOGIST
Authorized Official Telephone Number:
502-583-5834

Provider Taxonomy Codes

  • Taxonomy code: 1223P0106X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZD0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 151583XX . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5115678 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 78469 . This is a "AETNA BETTER HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2676260 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6701094-000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690009345 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: BP87-0001 . This is a "BC/BS MD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 000000247638 . This is a "ANTHEM BLUE CROSS BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 277243 . This is a "ANTHEM BCBS MC SUPP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3103049 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100173900 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000100269 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4409994 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50115665 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200364970A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30004761050 . This is a "CARESOURCE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 611948801 . This is a "US DEPT LABOR BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 93434 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01895510 . This is a "ANTHEM MA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 611948800 . This is a "US DEPT LABOR DEEOIC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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