Basic Information
| Provider Information | |||||||||
| NPI: | 1215936240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROSCIENCE ASSOCIATES OF NORTHERN KENTUCKY PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2845 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413412 | ||||||||
| FaxNumber: | 8593413171 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593413412 | ||||||||
| FaxNumber: | 8593413171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8593413412 | ||||||||
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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 | 363LP2300X | 1096049 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 65933947 | 05 | KY | MEDICAID | 6081204000 | 01 | KY | DOL | OTHER | DF1983 | 01 | KY | RAILROAD MEDICARE | OTHER |