Healthcare Provider Details

I. General information

NPI: 1700879491
Provider Name (Legal Business Name): NORTHERN KENTUCKY HEART PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 CENTRE VIEW BLVD
CRESTVIEW HILLS KY
41017-3476
US

IV. Provider business mailing address

380 CENTRE VIEW BLVD
CRESTVIEW HILLS KY
41017-3476
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-3015
  • Fax: 859-341-3215
Mailing address:
  • Phone: 859-341-3015
  • Fax: 859-341-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PATRICK GERAK
Title or Position: CHIEF OPERATION OFFICER
Credential:
Phone: 859-341-3015