Provider Demographics
NPI:1083124366
Name:KENTUCKIANA PAIN SPECIALIST AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:KENTUCKIANA PAIN SPECIALIST AMBULATORY SURGERY CENTER
Other - Org Name:KPS AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AJITH
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-995-4004
Mailing Address - Street 1:PO BOX 24321
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40224-0321
Mailing Address - Country:US
Mailing Address - Phone:502-995-4004
Mailing Address - Fax:502-933-5559
Practice Address - Street 1:3710 CHAMBERLAIN LN STE B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2002
Practice Address - Country:US
Practice Address - Phone:502-995-4004
Practice Address - Fax:502-933-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY36217174400000X
261QA1903X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies