1588797401 NPI number — MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES

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 1588797401 NPI number — MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
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:
6
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:
1588797401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
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:
803 MEYERS BAKER RD
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40741-3039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-862-9280
Provider Business Practice Location Address Fax Number:
606-877-3978
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REA
Authorized Official First Name:
KANDI
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PHYSICIAN CREDENTIALING
Authorized Official Telephone Number:
606-877-3931

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000377922 . This is a "ANTHEM GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65938177 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com