Healthcare Provider Details

I. General information

NPI: 1801806963
Provider Name (Legal Business Name): KENTUCKY HEART AND VASCULAR SPECIALISTS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 WOODLAND DR A
ELIZABETHTOWN KY
42701
US

IV. Provider business mailing address

1320 WOODLAND DR A
ELIZABETHTOWN KY
42701
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-2929
  • Fax: 270-769-0344
Mailing address:
  • Phone: 270-769-2929
  • Fax: 270-769-0344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number33792
License Number StateKY

VIII. Authorized Official

Name: DR. REDA A EL-SHIKEH
Title or Position: OWNER
Credential: M.D.
Phone: 270-769-2929