1316011059 NPI number — HAMBURG GASTROENTEROLOGY, PLLC

Table of content: (NPI 1316011059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316011059 NPI number — HAMBURG GASTROENTEROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAMBURG GASTROENTEROLOGY, 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:
1316011059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1795 ALYSHEBA WAY
Provider Second Line Business Mailing Address:
SUITE 1003
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-543-1777
Provider Business Mailing Address Fax Number:
859-543-1776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1795 ALYSHEBA WAY
Provider Second Line Business Practice Location Address:
SUITE 1003
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-543-1777
Provider Business Practice Location Address Fax Number:
859-543-1776
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JENNINGS-CONKLIN
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
GASTROENTEROLOGIST OWNER
Authorized Official Telephone Number:
859-543-1777

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  34156 , 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: 000000362844 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64066822 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00231447 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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