Basic Information
Provider Information | |||||||||
NPI: | 1073686143 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JAMES R ANGEL MD PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JAMES R ANGEL MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1698 OLD LEBANON RD | ||||||||
Address2: | SUITE 3B | ||||||||
City: | CAMPBELLSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427189662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707892471 | ||||||||
FaxNumber: | 2704654669 | ||||||||
Practice Location | |||||||||
Address1: | 1698 OLD LEBANON RD | ||||||||
Address2: | SUITE 3B | ||||||||
City: | CAMPBELLSVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427189662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707892471 | ||||||||
FaxNumber: | 2704654669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 04/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANGEL | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | RAYMOND | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2707892471 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 20672 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 00000062594 | 01 |   | BS | OTHER | 2440585000 | 01 |   | PASSPORT ADVANTAGE | OTHER | 64206725 | 05 | KY |   | MEDICAID | 1170188 | 01 |   | PASSPORT | OTHER |