Provider Demographics
NPI:1396774048
Name:INTERNAL MEDICINE ASSOCIATES OF KY PSC
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF KY PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DCOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-864-2179
Mailing Address - Street 1:2135 HIGHWAY 30 BYP
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-6139
Mailing Address - Country:US
Mailing Address - Phone:606-864-2179
Mailing Address - Fax:
Practice Address - Street 1:2135 HIGHWAY 30 BYP
Practice Address - Street 2:SUITE 1
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-6139
Practice Address - Country:US
Practice Address - Phone:606-864-2179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39044207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64094576Medicaid
KY64094576Medicaid
KYI25566Medicare UPIN