Provider Demographics
NPI:1508971722
Name:BUFFALO TRACE GASTROENTEROLOGY PLLC
Entity Type:Organization
Organization Name:BUFFALO TRACE GASTROENTEROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:JARRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-759-4869
Mailing Address - Street 1:991 MEDICAL PARK DR STE 203
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8728
Mailing Address - Country:US
Mailing Address - Phone:606-759-5157
Mailing Address - Fax:606-759-5582
Practice Address - Street 1:991 MEDICAL PARK DR STE 203
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8728
Practice Address - Country:US
Practice Address - Phone:606-759-5157
Practice Address - Fax:606-759-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34725207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00127Medicare ID - Type UnspecifiedMEDICARE NUMBER