Basic Information
| Provider Information | |||||||||
| NPI: | 1801833140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKIANA EMERGENCY PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4778 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474024778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 AUDUBON PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026367111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 03/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | BISHOP | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8778893383 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 164W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse | 207N00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207PE0004X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207PS0010X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine | 207P00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200226910 | 05 | IN | MEDICAID | 65932972 | 05 | KY | MEDICAID | 65909244 | 05 | KY | MEDICAID | 78905262 | 05 | KY | MEDICAID | 65931719 | 05 | KY | MEDICAID | 65931727 | 05 | KY | MEDICAID |