Provider Demographics
NPI:1700879491
Name:NORTHERN KENTUCKY HEART PSC
Entity Type:Organization
Organization Name:NORTHERN KENTUCKY HEART PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GERAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-341-3015
Mailing Address - Street 1:380 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3476
Mailing Address - Country:US
Mailing Address - Phone:859-341-3015
Mailing Address - Fax:859-341-3215
Practice Address - Street 1:380 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3476
Practice Address - Country:US
Practice Address - Phone:859-341-3015
Practice Address - Fax:859-341-3215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65939522Medicaid
KY78903259Medicaid
KY65939522Medicaid
KY7711Medicare PIN