Provider Demographics
NPI:1710115175
Name:SJL PHYSICIAN MANAGEMENT SERVICES INC.
Entity Type:Organization
Organization Name:SJL PHYSICIAN MANAGEMENT SERVICES INC.
Other - Org Name:DBA PREMIER HEART AND VASCULAR CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE & BUSINESS SERVICE
Authorized Official - Prefix:
Authorized Official - First Name:CARMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:606-877-3918
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:606-864-4040
Mailing Address - Fax:606-877-1722
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:606-864-4040
Practice Address - Fax:606-864-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-24
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207RC0000X, 207RC0001X, 207RI0011X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC21207OtherCHI
KY000000638615OtherANTHEM BCBS PIN
KYDP7481Medicare PIN
KYC21207OtherCHI