1699072967 NPI number — MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES

Table of content: (NPI 1699072967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699072967 NPI number — MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
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:
PREMIER ORTHOPEDICS & SPORTS MEDICINE DME
Provider Other Organization Name Type Code:
5
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:
1699072967
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 E LAUREL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40741-8601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-276-6611
Provider Business Mailing Address Fax Number:
859-276-5939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 LONDON MOUNTAIN VIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-864-0770
Provider Business Practice Location Address Fax Number:
606-864-1461
Provider Enumeration Date:
02/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CARMEL
Authorized Official Middle Name:
Authorized Official Title or Position:
COO/VP FINANCE
Authorized Official Telephone Number:
606-330-6015

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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)





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