1801951462 NPI number — ANDOVER FAMILY MEDICINE

Table of content: (NPI 1801951462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801951462 NPI number — ANDOVER FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDOVER FAMILY MEDICINE
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:
1801951462
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:
PO BOX 55168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40555-5168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-268-0254
Provider Business Mailing Address Fax Number:
859-263-0159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 PALUMBO DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-268-0254
Provider Business Practice Location Address Fax Number:
859-263-0159
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
859-268-0254

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  33166 , 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: 1224232 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000371547 . This is a "ANTHEM BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2075768 . This is a "FIRST HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2075768 . This is a "CCN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5276688 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65944324 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84146 . This is a "WASAU" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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