Basic Information
| Provider Information | |||||||||
| NPI: | 1336126515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKIERNAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950248 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022382801 | ||||||||
| FaxNumber: | 5022382835 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 KRESGE WAY | ||||||||
| Address2: | SUITE 56 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028957265 | ||||||||
| FaxNumber: | 5028972113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 18531 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0402X | 18531 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 64185317 | 05 | KY | MEDICAID | 2432390000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 1049109 | 01 | KY | PASSPORT | OTHER | 100373820 | 05 | IN | MEDICAID | P00719572 | 01 | KY | RAILTOAD MEDICARE | OTHER | 000000617819 | 01 | KY | ANTHEM | OTHER |