1619949971 NPI number — RETINA AND VITREOUS ASSOCIATES OF KENTUCKY PLLC

Table of content: (NPI 1619949971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619949971 NPI number — RETINA AND VITREOUS ASSOCIATES OF KENTUCKY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA AND VITREOUS ASSOCIATES OF KENTUCKY 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:
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:
1619949971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 N EAGLE CREEK DR
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-263-3900
Provider Business Mailing Address Fax Number:
859-263-3757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N EAGLE CREEK DR
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-263-3900
Provider Business Practice Location Address Fax Number:
859-263-3757
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GIRA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
PRAVOOT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
314-909-0633

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  1689DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100856500 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100871660 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0730481 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201209490A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007018000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com