Basic Information
| Provider Information | |||||||||
| NPI: | 1053450775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHEST MEDICINE ASSOCIATES PSC | ||||||||
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| OtherOrganizationName: | SLEEP MEDICINE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3430 NEWBURG RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402182497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022383178 | ||||||||
| FaxNumber: | 5022383653 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 NORTON HEALTHCARE BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402412847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026144179 | ||||||||
| FaxNumber: | 5026144450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | LACY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5024540269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 65934184 | 05 | KY | MEDICAID | 1052030 | 01 | KY | PASSPORT | OTHER |