Basic Information
Provider Information | |||||||||
NPI: | 1184776445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENTUCKY CARDIOLOGY CONSULTANTS, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1210 KY HIGHWAY 36E | ||||||||
Address2: | SUITE G3 | ||||||||
City: | CYNTHIANA | ||||||||
State: | KY | ||||||||
PostalCode: | 41031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592349222 | ||||||||
FaxNumber: | 8592345666 | ||||||||
Practice Location | |||||||||
Address1: | 1210 KY HIGHWAY 36E | ||||||||
Address2: | SUITE G3 | ||||||||
City: | CYNTHIANA | ||||||||
State: | KY | ||||||||
PostalCode: | 41031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592349222 | ||||||||
FaxNumber: | 8592345666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2007 | ||||||||
LastUpdateDate: | 12/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FALLUJI | ||||||||
AuthorizedOfficialFirstName: | NEZAR | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8592349222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 7100000890 | 05 | KY |   | MEDICAID |