Provider Demographics
NPI:1447213897
Name:GIANNINI, JACK THOMAS (PSC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:THOMAS
Last Name:GIANNINI
Suffix:
Gender:M
Credentials:PSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1963
Mailing Address - Country:US
Mailing Address - Phone:270-886-7512
Mailing Address - Fax:270-886-0174
Practice Address - Street 1:220 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1963
Practice Address - Country:US
Practice Address - Phone:270-886-7512
Practice Address - Fax:270-886-0174
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15869208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64158694Medicaid
610950799OtherTIN
D92444Medicare UPIN
KY64158694Medicaid