Basic Information
| Provider Information | |||||||||
| NPI: | 1700999703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALLEY | ||||||||
| FirstName: | J | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636961 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815130 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704420103 | ||||||||
| FaxNumber: | 2704420109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 21377 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 060060128 | 01 | RAILROAD MEDICARE | OTHER | 028189499 | 01 | DEPT OF LABOR | OTHER | 64213770 | 05 | KY | MEDICAID |