Healthcare Provider Details

I. General information

NPI: 1710115175
Provider Name (Legal Business Name): SJL PHYSICIAN MANAGEMENT SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W 5TH ST
LONDON KY
40741-2112
US

IV. Provider business mailing address

PO BOX 2638
LONDON KY
40743-2638
US

V. Phone/Fax

Practice location:
  • Phone: 606-864-4040
  • Fax: 606-864-3500
Mailing address:
  • Phone: 606-864-4040
  • Fax: 606-877-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: CARMEL JONES
Title or Position: VP REVENUE CYCLE & BUSINESS SERVICE
Credential: CPA
Phone: 606-877-3918