Basic Information
| Provider Information | |||||||||
| NPI: | 1386752756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEART SPECIALISTS OF SE KY PSC | ||||||||
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| OtherOrganizationName: | HEART SPECIALISTS OF SE KY PSC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 MOONBOW PLZ | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065239010 | ||||||||
| FaxNumber: | 6065235923 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 MOONBOW PLZ | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407018949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065239010 | ||||||||
| FaxNumber: | 6065235923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2006 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | OKUMA | ||||||||
| AuthorizedOfficialFirstName: | JANIE | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6065239010 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA249 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | 4069P | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 174400000X | 29557 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 65914996 | 05 | KY | MEDICAID |