Provider Demographics
NPI:1619165644
Name:KENTUCKY CARDIOVASCULAR CONSULTANTS PLLC
Entity Type:Organization
Organization Name:KENTUCKY CARDIOVASCULAR CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-926-2998
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG B, LL103
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-926-2998
Mailing Address - Fax:270-852-1653
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG B, LL103
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-926-2998
Practice Address - Fax:270-852-1653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32463207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100014630Medicaid
KY7100014630Medicaid
KY00539Medicare PIN
KY7100014630Medicaid