Basic Information
| Provider Information | |||||||||
| NPI: | 1285731497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST STOP URGENT CARE CENTER PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400319122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022220028 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400319122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022220028 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | DAVE | ||||||||
| AuthorizedOfficialFirstName: | KAMLESH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5026932465 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2694766000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 611378102 | 01 | KY | COMMERCIAL | OTHER | 1D31001092 | 05 | KY | MEDICAID | DD0597 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000344868 | 01 | KY | ANTHEM | OTHER | 500009943 | 01 | KY | PASSPORT | OTHER | 9241 | 01 | KY | MEDICARE | OTHER |