=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114276789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY PAIN ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2012
-----------------------------------------------------
Last Update Date | 08/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 SOUTH 1ST STREET SUITE 300
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-855-3919
-----------------------------------------------------
Fax | 502-855-3918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 SOUTH 1ST STREET SUITE 300
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-855-3919
-----------------------------------------------------
Fax | 502-855-3918
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JASON LEWIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 502-855-3919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 42621
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------