Provider Demographics
NPI:1689022972
Name:ADVANCED DIABETES MANAGEMENT PLLC
Entity Type:Organization
Organization Name:ADVANCED DIABETES MANAGEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AINES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-592-9254
Mailing Address - Street 1:4119 BROWNS LN
Mailing Address - Street 2:BLDG 2
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1500
Mailing Address - Country:US
Mailing Address - Phone:800-294-0807
Mailing Address - Fax:502-681-9883
Practice Address - Street 1:4119 BROWNS LN
Practice Address - Street 2:BLDG 2
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1500
Practice Address - Country:US
Practice Address - Phone:800-294-0807
Practice Address - Fax:502-681-9883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100442930Medicaid
KYK201460Medicare PIN