Healthcare Provider Details

I. General information

NPI: 1073686143
Provider Name (Legal Business Name): JAMES R ANGEL MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 OLD LEBANON RD SUITE 3B
CAMPBELLSVILLE KY
42718-9662
US

IV. Provider business mailing address

1698 OLD LEBANON RD SUITE 3B
CAMPBELLSVILLE KY
42718-9662
US

V. Phone/Fax

Practice location:
  • Phone: 270-789-2471
  • Fax: 270-465-4669
Mailing address:
  • Phone: 270-789-2471
  • Fax: 270-465-4669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20672
License Number StateKY

VIII. Authorized Official

Name: MR. JAMES RAYMOND ANGEL
Title or Position: OWNER
Credential: MD
Phone: 270-789-2471