1831411354 NPI number — KENTUCKY RIVER PHYSICIAN CORPORATION

Table of content: (NPI 1831411354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831411354 NPI number — KENTUCKY RIVER PHYSICIAN CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKY RIVER PHYSICIAN CORPORATION
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:
1831411354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1573 MALLORY LN STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
152-221-1400
Provider Business Mailing Address Fax Number:
615-465-3007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
726 HIGHWAY 15 N
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-666-2545
Provider Business Practice Location Address Fax Number:
606-666-2621
Provider Enumeration Date:
02/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FEY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SR. DIRECTOR PHYSICIAN REV CYCLE
Authorized Official Telephone Number:
615-221-3641

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  700199 , 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)





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