1528142999 NPI number — BEN A REID JR PSC

Table of content: (NPI 1528142999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528142999 NPI number — BEN A REID JR PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEN A REID JR PSC
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:
1528142999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4402 CHURCHMAN AVE
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40215-1190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-361-6070
Provider Business Mailing Address Fax Number:
502-363-7811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4402 CHURCHMAN AVE
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40215-1190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-361-6070
Provider Business Practice Location Address Fax Number:
502-363-7811
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
BEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SOLE MEMBER OWNER
Authorized Official Telephone Number:
502-361-6070

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  14503 , 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: 641145039 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1780036 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000046091 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1059433 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2434094000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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