Provider Demographics
NPI:1073686143
Name:JAMES R ANGEL MD PLLC
Entity Type:Organization
Organization Name:JAMES R ANGEL MD PLLC
Other - Org Name:JAMES R ANGEL MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-789-2471
Mailing Address - Street 1:1698 OLD LEBANON RD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9662
Mailing Address - Country:US
Mailing Address - Phone:270-789-2471
Mailing Address - Fax:270-465-4669
Practice Address - Street 1:1698 OLD LEBANON RD
Practice Address - Street 2:SUITE 3B
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9662
Practice Address - Country:US
Practice Address - Phone:270-789-2471
Practice Address - Fax:270-465-4669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20672208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000062594OtherBS
2440585000OtherPASSPORT ADVANTAGE
KY64206725Medicaid
1170188OtherPASSPORT
KY64206725Medicaid
1170188OtherPASSPORT