Provider Demographics
NPI:1427191717
Name:KENTUCKIANA ADULT MEDICINE SPECIALISTS
Entity Type:Organization
Organization Name:KENTUCKIANA ADULT MEDICINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ZHALET
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHARESTAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:502-459-4555
Mailing Address - Street 1:1169 EASTERN PKWY STE 2358
Mailing Address - Street 2:MEDICAL ARTS BLDING
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1415
Mailing Address - Country:US
Mailing Address - Phone:502-459-4555
Mailing Address - Fax:
Practice Address - Street 1:1169 EASTERN PKWY STE 2358
Practice Address - Street 2:MEDICAL ARTS BLDING
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1415
Practice Address - Country:US
Practice Address - Phone:502-459-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH33682Medicare UPIN
KY9192Medicare ID - Type Unspecified