Basic Information
| Provider Information | |||||||||
| NPI: | 1922001833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLORECTAL CARE OF NORTHERN KY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 272 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410050272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138912813 | ||||||||
| FaxNumber: | 5138911039 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 CHANCELLOR DR | ||||||||
| Address2: | STE 215 | ||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593419659 | ||||||||
| FaxNumber: | 8593419659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 08/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8593419659 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | DD6452 | 01 | OH | RAILROAD MEDICARE | OTHER | 2948949 | 05 | OH | MEDICAID | 200927190A | 05 | IN | MEDICAID |