Provider Demographics
NPI:1932406212
Name:PEYTON, RUSSELL E (NP)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:PEYTON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5132
Mailing Address - Country:US
Mailing Address - Phone:866-273-5392
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:200 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1661
Practice Address - Country:US
Practice Address - Phone:270-824-6655
Practice Address - Fax:270-824-6629
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100156510Medicaid
KY0000000733164OtherBCBS
KYP400043647Medicare PIN
KY7100156510Medicaid
KYK113830Medicare PIN
KYK019782Medicare PIN
KY0000000733164OtherBCBS
KYP400042250Medicare PIN