Basic Information
| Provider Information | |||||||||
| NPI: | 1285916916 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGS DAUGHTERS MEDICAL SPECIALTIES INC., | ||||||||
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| OtherOrganizationName: | KINGS DAUGHTERS MEDICAL SPECIALITES -GYNECOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2245 WINCHESTER AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063242554 | ||||||||
| FaxNumber: | 6063242581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | WHITLATCH | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6064084401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 363L00000X | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207V00000X | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0055090 | 05 | OH | MEDICAID |