Provider Demographics
NPI:1336230820
Name:PAIN MANAGEMENT KENTUCKY PSC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT KENTUCKY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KUNNATHU
Authorized Official - Middle Name:P
Authorized Official - Last Name:GEEVARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-366-7317
Mailing Address - Street 1:4402 CHURCHMAN AVE
Mailing Address - Street 2:SUITE 409
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1190
Mailing Address - Country:US
Mailing Address - Phone:502-366-7318
Mailing Address - Fax:
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:SUITE 409
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-366-7318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933921Medicaid
KY7689Medicare ID - Type Unspecified