Provider Demographics
NPI:1093833998
Name:KFOURY MEDICAL SPECIALISTS PLLC
Entity Type:Organization
Organization Name:KFOURY MEDICAL SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WAJDI
Authorized Official - Middle Name:S
Authorized Official - Last Name:KFOURY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-309-1806
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-2828
Mailing Address - Country:US
Mailing Address - Phone:606-309-1806
Mailing Address - Fax:606-657-5734
Practice Address - Street 1:1 TRILLIUM WAY
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8727
Practice Address - Country:US
Practice Address - Phone:606-309-1806
Practice Address - Fax:606-657-5734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38881207RI0200X
363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100010200Medicaid
KY000000521523OtherBCBS OF KY
KY000000521523OtherBCBS OF KY
KY7100010200Medicaid