Basic Information
| Provider Information | |||||||||
| NPI: | 1518121458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UMA PRIMARY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 E BROADWAY | ||||||||
| Address2: | #290 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022178221 | ||||||||
| FaxNumber: | 5022175056 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | #370 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025626510 | ||||||||
| FaxNumber: | 5025626515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROMAN | ||||||||
| AuthorizedOfficialFirstName: | JESSE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5028525241 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100106840 (ARNPS) | 05 | KY | MEDICAID | 50020522 | 01 | KY | PASSPORT HEALTH PLAN | OTHER | 7100050240 (MDS) | 05 | KY | MEDICAID |