Basic Information
| Provider Information | |||||||||
| NPI: | 1790891125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKIANA ALLERGY PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9113 LEESGATE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024261621 | ||||||||
| FaxNumber: | 5024267906 | ||||||||
| Practice Location | |||||||||
| Address1: | 9113 LEESGATE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024261621 | ||||||||
| FaxNumber: | 5024267906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/MD | ||||||||
| AuthorizedOfficialTelephone: | 5024261621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207K00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 65915878 | 05 | KY | MEDICAID | 7100036520 | 05 | KY | MEDICAID | 100389960A | 05 | IN | MEDICAID |