Healthcare Provider Details

I. General information

NPI: 1265512719
Provider Name (Legal Business Name): BEVERLY M GAINES, MD & ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BARRET AVE SUITE 314
LOUISVILLE KY
40204-1747
US

IV. Provider business mailing address

801 BARRET AVE SUITE 314
LOUISVILLE KY
40204-1747
US

V. Phone/Fax

Practice location:
  • Phone: 502-585-2924
  • Fax: 502-585-2931
Mailing address:
  • Phone: 502-585-2924
  • Fax: 502-585-2931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY M GAINES
Title or Position: PRESIDENT & CEO
Credential: M.D.
Phone: 502-585-2924