Provider Demographics
NPI:1689674186
Name:KENTUCKY GERIATRICS PSC
Entity Type:Organization
Organization Name:KENTUCKY GERIATRICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUBERI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-544-6442
Mailing Address - Street 1:PO BOX 950231
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0231
Mailing Address - Country:US
Mailing Address - Phone:502-814-3170
Mailing Address - Fax:502-814-3196
Practice Address - Street 1:1705 HERR LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6545
Practice Address - Country:US
Practice Address - Phone:502-544-6442
Practice Address - Fax:502-426-5493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDD4794OtherRAILROAD MEDICARE
KY65943813Medicaid
KY65943813Medicaid