Basic Information
| Provider Information | |||||||||
| NPI: | 1083627087 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KISHORE INTERNAL MEDICINE, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N EAGLE CREEK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592634341 | ||||||||
| FaxNumber: | 8592637441 | ||||||||
| Practice Location | |||||||||
| Address1: | 94 MARIE LANGDON DR | ||||||||
| Address2: | STE 2 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 409626353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065990200 | ||||||||
| FaxNumber: | 6065990202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JADHAV | ||||||||
| AuthorizedOfficialFirstName: | KISHORE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6065990200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 31-000839 | 05 | KY | MEDICAID |