Basic Information
| Provider Information | |||||||||
| NPI: | 1801869292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMSURG NORTHERN KENTUCKY GI LLC | ||||||||
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| OtherOrganizationName: | ST. ELIZABETH PHYSICIANS ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD | ||||||||
| Address2: | ATTN: L&C | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593316466 | ||||||||
| FaxNumber: | 8593311932 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 THOMAS MORE PKWY | ||||||||
| Address2: | SUITE 160B | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593316466 | ||||||||
| FaxNumber: | 8593311932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 300131 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00883600 | 01 | KY | RAILROAD MEDICARE | OTHER | 7100153030 | 05 | KY | MEDICAID | 2278324 | 05 | OH | MEDICAID |