Basic Information
| Provider Information | |||||||||
| NPI: | 1174528392 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENDALL E HANSEN MD PLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERVENTIONAL PAIN SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410220634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599570700 | ||||||||
| FaxNumber: | 8599570703 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 THOMAS MORE PKWY. | ||||||||
| Address2: | STE. 260 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599570700 | ||||||||
| FaxNumber: | 8599570703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | KENDALL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D., PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8599570700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65933624 | 05 | KY | MEDICAID |