Provider Demographics
NPI:1780697037
Name:TUSSEY, GROVER MARK (MD)
Entity type:Individual
Prefix:
First Name:GROVER
Middle Name:MARK
Last Name:TUSSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1820
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40602-1820
Mailing Address - Country:US
Mailing Address - Phone:502-226-3858
Mailing Address - Fax:502-223-9829
Practice Address - Street 1:107 DIAGNOSTIC DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6524
Practice Address - Country:US
Practice Address - Phone:502-875-9885
Practice Address - Fax:502-875-9882
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37602207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64057623Medicaid
KY64057623Medicaid
KY1780697037Medicare PIN