1962476200 NPI number — SATHYENDRA R MYSORE M.D.

Table of content: SATHYENDRA R MYSORE M.D. (NPI 1962476200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962476200 NPI number — SATHYENDRA R MYSORE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYSORE
Provider First Name:
SATHYENDRA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1962476200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2013
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:
606-877-3931
Provider Business Mailing Address Fax Number:
606-877-3978

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 SAINT JOSEPH LN
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:
40741-8345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-330-6000
Provider Business Practice Location Address Fax Number:
606-330-7825
Provider Enumeration Date:
02/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  36943 , 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: 61-1427889 . This is a "CHA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 61-1427889 . This is a "TRICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 61-1427889 . This is a "BLUEGRASS FAMILY HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 61-1427889 . This is a "UHC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 61-1427889 . This is a "HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 030670000 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50005320 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64060783 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000378002 . This is a "ANTHEM PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: C20852 . This is a "CUMBERLAND HEALTHCARE INC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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