Basic Information
| Provider Information | |||||||||
| NPI: | 1154623825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KITE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 GLENRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | COLD SPRING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410769086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138072332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 MEDICAL VILLAGE DR | ||||||||
| Address2: | STE 258 INDEPENDENT ANESTHESIOLOGISTS | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1112744 | KY | N | Nursing Service Providers | Registered Nurse | 367500000X | 86720 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3123597 | 05 | OH | MEDICAID | 201012210 | 05 | IN | MEDICAID | 000000691665 | 01 | ANTHEM | OTHER | 7100146600 | 05 | KY | MEDICAID |