Provider Demographics
NPI:1164654851
Name:OWENSBORO MEDICAL INTERNISTS PSC
Entity Type:Organization
Organization Name:OWENSBORO MEDICAL INTERNISTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NITYANAND
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-240-5696
Mailing Address - Street 1:2816 VEACH RD STE 306
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-6297
Mailing Address - Country:US
Mailing Address - Phone:270-240-5696
Mailing Address - Fax:270-240-5697
Practice Address - Street 1:2816 VEACH RD STE 3-306
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-6295
Practice Address - Country:US
Practice Address - Phone:270-240-5696
Practice Address - Fax:270-240-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100112820Medicaid
KY7100112820Medicaid
KY01114Medicare PIN