Basic Information
Provider Information | |||||||||
NPI: | 1154464220 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARRICATO | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: | DEAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 780982 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191780982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033067783 | ||||||||
FaxNumber: | 3033067753 | ||||||||
Practice Location | |||||||||
Address1: | 200 E CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402021831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026298000 | ||||||||
FaxNumber: | 3033067753 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 04/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 41860 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 200918710 | 01 | IN | MEDICAID - IN - WS | OTHER | P00869561 | 01 | KY | RAILROAD MEDICARE - KY | OTHER | 000000583717 | 01 | KY | ANTHEM - WS | OTHER | 00533058 | 01 | KY | MEDICARE - CMA | OTHER | 50021447 | 01 | KY | PASSPORT - WS | OTHER | 099159 | 01 | KY | SIHO - WS | OTHER | 7100061820 | 01 | KY | MEDICAID - W SP | OTHER | 3552751000 | 01 | KS | PASSPORT ADVTG - WS | OTHER |