1548273733 NPI number — DERMATOPATHOLOGY ALLIANCE OF KENTUCKY PLLC

Table of Contents

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: 207ZP0102X ; 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" .

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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