Healthcare Provider Details

I. General information

NPI: 1255582755
Provider Name (Legal Business Name): INTERNAL MEDICINE CONSULTANTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E GRAY ST STE 670
LOUISVILLE KY
40202-1901
US

IV. Provider business mailing address

234 E GRAY ST STE 670
LOUISVILLE KY
40202-1901
US

V. Phone/Fax

Practice location:
  • Phone: 502-629-4525
  • Fax: 502-629-4529
Mailing address:
  • Phone: 502-629-4525
  • Fax: 502-629-4529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3008115
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006356
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36067
License Number StateKY

VIII. Authorized Official

Name: MR. JUAN G POLO
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 502-629-4525