Provider Demographics
NPI:1740694421
Name:INFECTIOUS DISEASES SPECIALISTS OF KENTUCKIANA LLC
Entity type:Organization
Organization Name:INFECTIOUS DISEASES SPECIALISTS OF KENTUCKIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-949-3242
Mailing Address - Street 1:17027 ASHBURTON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3725
Practice Address - Country:US
Practice Address - Phone:812-949-3242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201244550Medicaid
KY7100359690Medicaid
KYDV8435OtherRAILROAD MEDICARE
KY7100447670Medicaid
IN000000883842OtherANTHEM
INDV0764OtherRAILROAD MEDICARE
KY7100447670Medicaid
KYDV8435OtherRAILROAD MEDICARE