Basic Information
| Provider Information | |||||||||
| NPI: | 1790784320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAGATA | ||||||||
| FirstName: | ARDEL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAGATA | ||||||||
| OtherFirstName: | ARDYLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E CHESTNUT ST | ||||||||
| Address2: | SERVICES BLDG, STE 303 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026296552 | ||||||||
| FaxNumber: | 5026293132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30478 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 30478 | KY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 000000625001 | 01 | KY | ANTHEM - NICS | OTHER | 055105 | 01 | KY | SIHO - NICS | OTHER | 3682676 | 01 | KY | CIGNA - NICS | OTHER | 3730062000 | 01 | KY | PASSPORT ADVANTAGE - NICS | OTHER | 611276316U | 01 | KY | HUMANA - NICS | OTHER | 64304785 | 05 | KY | MEDICAID | 50025123 | 01 | KY | PASSPORT - NICS | OTHER | 200270800 | 05 | IN | MEDICAID |