Provider Demographics
NPI:1326340886
Name:J MICHAEL GIANNINI PSC
Entity Type:Organization
Organization Name:J MICHAEL GIANNINI PSC
Other - Org Name:J MICHAEL GIANNINI MD PSC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GIANNINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-444-7248
Mailing Address - Street 1:2138 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7110
Mailing Address - Country:US
Mailing Address - Phone:270-444-7248
Mailing Address - Fax:270-444-6014
Practice Address - Street 1:2138 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7110
Practice Address - Country:US
Practice Address - Phone:270-444-7248
Practice Address - Fax:270-444-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17473207N00000X
IL036091667207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64174733Medicaid
KY64174733Medicaid
IL377740Medicare PIN