1720009665 NPI number — PROMPTCARE PHYSICIAN GROUP 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 1720009665 NPI number — PROMPTCARE PHYSICIAN GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMPTCARE PHYSICIAN GROUP 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:
1720009665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3215 WESTPORT GREEN PL
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:
40241-3135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-412-1112
Provider Business Mailing Address Fax Number:
502-357-0606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3215 WESTPORT GREEN PL
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:
40241-3135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-412-1112
Provider Business Practice Location Address Fax Number:
502-357-0606
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHANKS
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
MANGER
Authorized Official Telephone Number:
502-412-1112

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000061352 . This is a "ANTHEM BSBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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