Provider Demographics
NPI:1811195522
Name:KENTUCKIANA PERINATOLOGY, PSC
Entity Type:Organization
Organization Name:KENTUCKIANA PERINATOLOGY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CODING
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:HAWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:CRT, CPC, CPC-H,CIMC
Authorized Official - Phone:502-582-5999
Mailing Address - Street 1:210 E GRAY ST
Mailing Address - Street 2:SUITE 803
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3902
Mailing Address - Country:US
Mailing Address - Phone:502-582-6900
Mailing Address - Fax:502-582-5400
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 803
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3902
Practice Address - Country:US
Practice Address - Phone:502-582-6900
Practice Address - Fax:502-582-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29075207V00000X, 207VM0101X
KY3003321363L00000X
KY3005620363L00000X
KY1101722363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D21141Medicare UPIN