Basic Information
| Provider Information | |||||||||
| NPI: | 1710951116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307808 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SAINT JOSEPH LANE | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063306000 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | REA | ||||||||
| AuthorizedOfficialFirstName: | KANDI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6063307808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RE0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2080A0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2084N0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | 40293 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208M00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AS0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 213ES0103X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 65938177 | 05 | KY | MEDICAID |