Provider Demographics
NPI:1649350232
Name:GAINES, BEVERLY M (MD)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:M
Last Name:GAINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 W BROADWAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2129
Mailing Address - Country:US
Mailing Address - Phone:502-585-2924
Mailing Address - Fax:502-585-2931
Practice Address - Street 1:305 W BROADWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2129
Practice Address - Country:US
Practice Address - Phone:502-585-2924
Practice Address - Fax:502-585-2931
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-12-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY20974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64209745Medicaid
KY64209745Medicaid