Basic Information
| Provider Information | |||||||||
| NPI: | 1215962212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKIANA HEART & VASCULAR SPECIALISTS PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 EAST PARRISH AVENUE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262998 | ||||||||
| FaxNumber: | 2709261181 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 EAST PARRISH AVENUE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262998 | ||||||||
| FaxNumber: | 2709261181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUPTA | ||||||||
| AuthorizedOfficialFirstName: | MUKESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT OF CORPORATION | ||||||||
| AuthorizedOfficialTelephone: | 2709262998 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65909848 | 05 | KY | MEDICAID |