1366407447 NPI number — KONSTANTINOS G SKANDAMIS M.D.

Table of content: KONSTANTINOS G SKANDAMIS M.D. (NPI 1366407447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366407447 NPI number — KONSTANTINOS G SKANDAMIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKANDAMIS
Provider First Name:
KONSTANTINOS
Provider Middle Name:
G
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:
1366407447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 BISHOP LN
Provider Second Line Business Practice Location Address:
STE 1600
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-1921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-272-5100
Provider Business Practice Location Address Fax Number:
502-272-5116
Provider Enumeration Date:
04/20/2006

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: 207Q00000X , with the licence number:  38006 , 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: 200505860 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13219442 . This is a "CHA- NORTON ICC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00293208 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000382368 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200505860 . This is a "HEALTHY INDIANA PLAN- NORTON ICC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: P00305292 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 047513 . This is a "SIHO" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200505860 . This is a "ANTHEM INDIANA MEDICAID- NORTON ICC" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200505860 . This is a "MD WISE- NORTON IMMEDIATE CARE CENTER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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