Healthcare Provider Details

I. General information

NPI: 1588057897
Provider Name (Legal Business Name): KIOSK MEDICINE OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W JOHN ROWAN BLVD
BARDSTOWN KY
40004-2663
US

IV. Provider business mailing address

PO BOX 932958
CLEVELAND OH
44193-0028
US

V. Phone/Fax

Practice location:
  • Phone: 502-348-7880
  • Fax: 502-348-7881
Mailing address:
  • Phone: 615-425-4200
  • Fax: 615-425-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS SHELLY
Title or Position: VP & GENERAL MANAGER
Credential:
Phone: 615-425-4287