Provider Demographics
NPI:1114265923
Name:MATTHEW C BIRDWHISTELL DO LLC
Entity Type:Organization
Organization Name:MATTHEW C BIRDWHISTELL DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:BIRDWHISTELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-863-0721
Mailing Address - Street 1:1138 LEXINGTON RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9672
Mailing Address - Country:US
Mailing Address - Phone:502-863-0721
Mailing Address - Fax:502-863-6104
Practice Address - Street 1:1138 LEXINGTON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9672
Practice Address - Country:US
Practice Address - Phone:502-863-0721
Practice Address - Fax:502-863-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100160510Medicaid
KYK017680Medicare PIN