Healthcare Provider Details

I. General information

NPI: 1386752756
Provider Name (Legal Business Name): HEART SPECIALISTS OF SE KY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOONBOW PLZ
CORBIN KY
40701-8949
US

IV. Provider business mailing address

45 MOONBOW PLZ
CORBIN KY
40701-8949
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-9010
  • Fax: 606-523-5923
Mailing address:
  • Phone: 606-523-9010
  • Fax: 606-523-5923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA249
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4069P
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number29557
License Number StateKY

VIII. Authorized Official

Name: JANIE RENEE OKUMA
Title or Position: OFFICE MANAGER
Credential:
Phone: 606-523-9010