Provider Demographics
NPI: | 1710951116 |
---|---|
Name: | MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES |
Entity Type: | Organization |
Organization Name: | MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | KANDI |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | REA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 606-330-7808 |
Mailing Address - Street 1: | 740 E LAUREL RD |
Mailing Address - Street 2: | |
Mailing Address - City: | LONDON |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40741-8601 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 606-330-7808 |
Mailing Address - Fax: | 606-330-7825 |
Practice Address - Street 1: | 1001 SAINT JOSEPH LANE |
Practice Address - Street 2: | |
Practice Address - City: | LONDON |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40741-8345 |
Practice Address - Country: | US |
Practice Address - Phone: | 606-330-6000 |
Practice Address - Fax: | 606-330-7825 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-02-14 |
Last Update Date: | 2011-06-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
207L00000X, 207Q00000X, 207RE0101X, 207RP1001X, 207X00000X, 2080A0000X, 2084N0400X, 2085R0202X, 208G00000X, 208M00000X, 213ES0103X, 261QR1300X, 363AS0400X, 363LF0000X | ||
KY | 40293 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Single Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Single Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Single Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Single Specialty | |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | Group - Single Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Single Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Single Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Single Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Single Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Single Specialty | |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Single Specialty |
No | 261QR1300X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | Group - Single Specialty |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Single Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 65938177 | Medicaid | |
KY | 65938177 | Medicaid |