=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215087903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TPG PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 KENTUCKY AVE SUITE 102
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-575-0555
-----------------------------------------------------
Fax | 270-575-3005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 KENTUCKY AVE SUITE 102
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-575-0555
-----------------------------------------------------
Fax | 270-575-3005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TODD P GINESTRA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-575-0555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 36025
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------