1619986973 NPI number — DENNIS S PEPPAS MD

Table of content: DENNIS S PEPPAS MD (NPI 1619986973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619986973 NPI number — DENNIS S PEPPAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEPPAS
Provider First Name:
DENNIS
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1619986973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776879
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:
60677-6879
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:
4123 DUTCHMAN'S LANE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-5832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-559-1670
Provider Business Practice Location Address Fax Number:
502-559-1679
Provider Enumeration Date:
08/05/2006

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: 208800000X , with the licence number:  48025 , 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: 168822802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168822801 . This is a "CIDC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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