Provider Demographics
NPI:1487657268
Name:GHOSH, SUBIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBIR
Middle Name:
Last Name:GHOSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0907
Mailing Address - Country:US
Mailing Address - Phone:606-666-5142
Mailing Address - Fax:606-666-4172
Practice Address - Street 1:832 HWY 15 NORTH
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8601
Practice Address - Country:US
Practice Address - Phone:606-666-5142
Practice Address - Fax:606-666-4172
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38152207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64073885Medicaid
0660306Medicare PIN
KYH49898Medicare UPIN