1881765204 NPI number — KENTUCKY NEPHROLOGY RESEARCH TRUST, INC.

Table of content: (NPI 1881765204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881765204 NPI number — KENTUCKY NEPHROLOGY RESEARCH TRUST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKY NEPHROLOGY RESEARCH TRUST, INC.
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:
1881765204
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 SAINT ANN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42303-4145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 WINCHESTER RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40505-4028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-225-4595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
270-684-2110

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  300147 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QE0700X , with the licence number: 300147 , 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: 39000492 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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