Provider Demographics
NPI:1114176682
Name:MOHAMMAD K GAYASADDIN
Entity Type:Organization
Organization Name:MOHAMMAD K GAYASADDIN
Other - Org Name:MOHAMMAD K GAYASADDIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:K
Authorized Official - Last Name:GAYASADDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-765-2220
Mailing Address - Street 1:914 N DIXIE AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2515
Mailing Address - Country:US
Mailing Address - Phone:270-765-2220
Mailing Address - Fax:270-765-2226
Practice Address - Street 1:914 N DIXIE AVE STE 301
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2515
Practice Address - Country:US
Practice Address - Phone:270-765-2220
Practice Address - Fax:270-765-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39269174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64092166Medicaid
KYD77164Medicare UPIN
KY1968601Medicare PIN