Basic Information
| Provider Information | |||||||||
| NPI: | 1588797401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES | ||||||||
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| OtherOrganizationName: | LONDON CARDIO-VASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068773931 | ||||||||
| FaxNumber: | 6068773978 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 MEYERS BAKER RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407413039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068629280 | ||||||||
| FaxNumber: | 6068773978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | REA | ||||||||
| AuthorizedOfficialFirstName: | KANDI | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6068773931 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 000000377922 | 01 | KY | ANTHEM GROUP | OTHER | 65938177 | 05 | KY | MEDICAID |