Basic Information
| Provider Information | |||||||||
| NPI: | 1184776445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY CARDIOLOGY CONSULTANTS, PLLC | ||||||||
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| 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 | ||||||||
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| AuthorizedOfficialLastName: | FALLUJI | ||||||||
| AuthorizedOfficialFirstName: | NEZAR | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8592349222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 |