Provider Demographics
NPI:1093971541
Name:KENTUCKY GASTROENTEROLOGY PSC
Entity Type:Organization
Organization Name:KENTUCKY GASTROENTEROLOGY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADEEM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-625-0900
Mailing Address - Street 1:793 EASTERN BYP
Mailing Address - Street 2:SUITE 216
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2422
Mailing Address - Country:US
Mailing Address - Phone:859-625-0900
Mailing Address - Fax:859-625-0995
Practice Address - Street 1:793 EASTERN BYP
Practice Address - Street 2:SUITE 216
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2422
Practice Address - Country:US
Practice Address - Phone:859-625-0900
Practice Address - Fax:859-625-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000579699OtherANTHEM BCBS
KY64333818Medicaid
KY000000579699OtherANTHEM BCBS