Healthcare Provider Details

I. General information

NPI: 1417040742
Provider Name (Legal Business Name): KUNNATHU P. GEEVARGHESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 CHURCHMAN AVE SUITE 302
LOUISVILLE KY
40215-1190
US

IV. Provider business mailing address

4402 CHURCHMAN AVE SUITE 302
LOUISVILLE KY
40215-1190
US

V. Phone/Fax

Practice location:
  • Phone: 502-366-7317
  • Fax: 502-366-7318
Mailing address:
  • Phone: 502-366-7317
  • Fax: 502-366-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16440
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number16440
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: