Provider Demographics
NPI:1417915661
Name:KENTUCKY INPATIENT MEDICINE ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:KENTUCKY INPATIENT MEDICINE ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TALBOT
Authorized Official - Middle Name:GREEN
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:678-441-8508
Mailing Address - Street 1:5901-C PEACHTREE-DUNWOODY ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-7159
Mailing Address - Country:US
Mailing Address - Phone:678-441-8556
Mailing Address - Fax:678-441-8656
Practice Address - Street 1:1 SAINT JOSEPH DR
Practice Address - Street 2:SAINT JOSEPH HOSPITAL,
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3742
Practice Address - Country:US
Practice Address - Phone:859-313-2963
Practice Address - Fax:785-623-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207P00000X, 207Q00000X, 207R00000X, 208D00000X, 208M00000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCH2140OtherRR MEDICARE - GROUP
KY33J2OtherBCBS - GROUP
KY65901613Medicaid
KY78901162OtherKY MEDICAID - NP GROUP
KY6148Medicare PIN
KY65901613Medicaid
KY6147Medicare PIN
KY6148Medicare PIN
KY9398Medicare PIN
KY7583Medicare PIN