Basic Information
| Provider Information | |||||||||
| NPI: | 1801144852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGS DAUGHTERS MEDICAL SPECIALTIES INC., | ||||||||
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| OtherOrganizationName: | KINGS DAUGHTERS MEDICAL SPECIALTIES ANESTHESIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7376 SOLUTION CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606772379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411012843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064084000 | ||||||||
| FaxNumber: | 6064085176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2012 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | WHITLATCH | ||||||||
| AuthorizedOfficialFirstName: | KRISTY | ||||||||
| 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 | 367500000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363L00000X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207L00000X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0072175 | 05 | OH | MEDICAID | 7100231840 | 05 | KY | MEDICAID | 7100231890 | 05 | KY | MEDICAID |