Provider Demographics
NPI:1073671673
Name:JAENICKE, KURT (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:JAENICKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5009
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-5009
Mailing Address - Country:US
Mailing Address - Phone:615-221-1400
Mailing Address - Fax:
Practice Address - Street 1:412 N LOCK AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1115
Practice Address - Country:US
Practice Address - Phone:606-638-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31309207VF0040X, 207V00000X
WV16950207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163719Medicaid
KY000000583794OtherANTHEM BCBS
KY64313091Medicaid
KY000000510048OtherANTHEM BCBS
KYP00641261Medicare PIN
KY00399001Medicare PIN
KY64313091Medicaid
KYP00412625Medicare PIN