Basic Information
| Provider Information | |||||||||
| NPI: | 1386683167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIGAM | ||||||||
| FirstName: | KUSUM | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 CHURCHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402151190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023676322 | ||||||||
| FaxNumber: | 5023803843 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST BLDG SUITE303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295552 | ||||||||
| FaxNumber: | 5026293137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 32516 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64030026 | 05 | KY | MEDICAID |