Provider Demographics
NPI:1295090884
Name:KENTUCKY MEDICAL SPECIALISTS, PSC
Entity type:Organization
Organization Name:KENTUCKY MEDICAL SPECIALISTS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHAGUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-893-7372
Mailing Address - Street 1:4001 KRESGE WAY STE # 236
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207
Mailing Address - Country:US
Mailing Address - Phone:502-893-7372
Mailing Address - Fax:502-409-4715
Practice Address - Street 1:4001 KRESGE WAY STE # 236
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-893-7372
Practice Address - Fax:502-409-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 363LA2200X
KY36325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64063266Medicaid
KY7100235310Medicaid