Basic Information
| Provider Information | |||||||||
| NPI: | 1629153705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EUGENE GILES SR MD PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OMNI MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2746 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402113417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027761177 | ||||||||
| FaxNumber: | 5027721761 | ||||||||
| Practice Location | |||||||||
| Address1: | 2746 VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402113417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027761177 | ||||||||
| FaxNumber: | 5027721761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 02/24/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILES | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOLO MEMBER OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5027761177 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22657 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 22657 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0400136 | 01 | UNITED HEALTHCARE | OTHER | 1049423 | 01 | KY | PASSPORT | OTHER | 64226574 | 05 | KY | MEDICAID | 000000062872 | 01 | KY | ANTHEM | OTHER |