1417066424 NPI number — BURKESVILLE MEDICAL SUPPLY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417066424 NPI number — BURKESVILLE MEDICAL SUPPLY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURKESVILLE MEDICAL SUPPLY, INC
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:
1417066424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42717-0006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-864-2230
Provider Business Mailing Address Fax Number:
270-864-2691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 KEEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURKESVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42717-0006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-864-2230
Provider Business Practice Location Address Fax Number:
270-864-2691
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER CEO
Authorized Official Telephone Number:
270-864-2230

Provider Taxonomy Codes

  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: MG0187 , 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: 000000070347 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 006895400 . This is a "BLACK LUNG" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100164320 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90040296 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45906005 . This is a "ESPDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100165970 . This is a "ESDPT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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