Basic Information
| Provider Information | |||||||||
| NPI: | 1417915661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY INPATIENT MEDICINE ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901-C PEACHTREE-DUNWOODY ROAD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303287159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784418556 | ||||||||
| FaxNumber: | 6784418656 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT JOSEPH DR | ||||||||
| Address2: | SAINT JOSEPH HOSPITAL, | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593132963 | ||||||||
| FaxNumber: | 7856235045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | TALBOT | ||||||||
| AuthorizedOfficialMiddleName: | GREEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6784418508 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208M00000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | CH2140 | 01 | KY | RR MEDICARE - GROUP | OTHER | 33J2 | 01 | KY | BCBS - GROUP | OTHER | 65901613 | 05 | KY | MEDICAID | 78901162 | 01 | KY | KY MEDICAID - NP GROUP | OTHER |