Provider Demographics
NPI:1619200151
Name:MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
Other - Org Name:PULMONARY & SLEEP SPECIALISTS OF LONDON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KANDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:REA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-330-3404
Mailing Address - Street 1:PO BOX 2638
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-2638
Mailing Address - Country:US
Mailing Address - Phone:606-330-3404
Mailing Address - Fax:606-330-3100
Practice Address - Street 1:1210 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2112
Practice Address - Country:US
Practice Address - Phone:606-864-4030
Practice Address - Fax:606-864-0115
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-16
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty