Basic Information
| Provider Information | |||||||||
| NPI: | 1710115175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SJL PHYSICIAN MANAGEMENT SERVICES INC. | ||||||||
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| OtherOrganizationName: | DBA PREMIER HEART AND VASCULAR CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2638 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407432638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068644040 | ||||||||
| FaxNumber: | 6068771722 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407412112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068644040 | ||||||||
| FaxNumber: | 6068643500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CARMEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE & BUSINESS SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 6068773918 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 363A00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | C21207 | 01 | KY | CHI | OTHER | 000000638615 | 01 | KY | ANTHEM BCBS PIN | OTHER |