1922001833 NPI number — COLORECTAL CARE OF NORTHERN KY, PLLC

Table of content: (NPI 1922001833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922001833 NPI number — COLORECTAL CARE OF NORTHERN KY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLORECTAL CARE OF NORTHERN KY, 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:
1922001833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41005-0272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-891-2813
Provider Business Mailing Address Fax Number:
513-891-1039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2865 CHANCELLOR DR
Provider Second Line Business Practice Location Address:
STE 215
Provider Business Practice Location Address City Name:
CRESTVIEW HILLS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41017-3912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-9659
Provider Business Practice Location Address Fax Number:
859-341-9659
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
859-341-9659

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DD6452 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2948949 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200927190A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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