Basic Information
Provider Information | |||||||||
NPI: | 1386611994 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | LOU | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3785 RELIABLE PARKWAY | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606860037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162813700 | ||||||||
FaxNumber: | 3162824322 | ||||||||
Practice Location | |||||||||
Address1: | 2201 LEXINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 41101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063274000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2006 | ||||||||
LastUpdateDate: | 06/16/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1830A | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0136856 | 01 | OH | OHIO MEDICAID | OTHER | 0068530000 | 01 | WV | WEST VIRGINIA MEDICAID | OTHER | 74003682 | 05 | KY |   | MEDICAID | 000000209844 | 01 | KY | ANTHEM BLUE CROSS BLUE SHIELD | OTHER |