Basic Information
Provider Information | |||||||||
NPI: | 1730638750 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | U.S. HEALTHWORKS MEDICAL GROUP OF KENTUCKY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25124 SPRINGFIELD CT | ||||||||
Address2: | 200 | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913551085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6616782600 | ||||||||
FaxNumber: | 6616782700 | ||||||||
Practice Location | |||||||||
Address1: | 100 HIGH RISE DR | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402133251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5029643688 | ||||||||
FaxNumber: | 5029687146 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2016 | ||||||||
LastUpdateDate: | 10/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MALLAS | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHEIF EXECTUTIVE OFFICE | ||||||||
AuthorizedOfficialTelephone: | 6616782600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | U.S. HEALTHWORKS MEDICAL GROUP OF KENTUCKY, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.