Basic Information
| Provider Information | |||||||||
| NPI: | 1699725598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKIANA PULMONARY ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950154 DEPT 52937 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025878000 | ||||||||
| FaxNumber: | 5025838001 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W MARKET ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025878000 | ||||||||
| FaxNumber: | 5025838001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCCONNELL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | WESLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5025878000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200203050 | 05 | IN | MEDICAID | 65930935 | 05 | KY | MEDICAID |