Provider Demographics
NPI:1629153705
Name:EUGENE GILES SR MD PSC
Entity Type:Organization
Organization Name:EUGENE GILES SR MD PSC
Other - Org Name:OMNI MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLO MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GILES
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-776-1177
Mailing Address - Street 1:2746 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-3417
Mailing Address - Country:US
Mailing Address - Phone:502-776-1177
Mailing Address - Fax:502-772-1761
Practice Address - Street 1:2746 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-3417
Practice Address - Country:US
Practice Address - Phone:502-776-1177
Practice Address - Fax:502-772-1761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22657207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0400136OtherUNITED HEALTHCARE
KY1049423OtherPASSPORT
KY64226574Medicaid
KY000000062872OtherANTHEM
3200Medicare PIN
DD6406Medicare PIN
KY000000062872OtherANTHEM