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General NPI Number Information
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NPI Number | 1295090884
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Entity Type | Organization
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Legal Business Name | KENTUCKY MEDICAL SPECIALISTS, PSC
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Dates
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Enumeration Date | 07/10/2012
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Last Update Date | 05/01/2019
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Provider Practice Location Address
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Address Line | 4001 KRESGE WAY STE # 236
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City | LOUISVILLE
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State | KY
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Zip | 40207
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Country | US
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Telephone | 502-893-7372
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Fax | 502-409-4715
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Provider Business Mailing Address
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Address Line | 4001 KRESGE WAY STE # 236
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City | LOUISVILLE
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State | KY
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Zip | 40207
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Country | US
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Telephone | 502-893-7372
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Fax | 502-409-4715
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARLON R CHAGUA
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Credential | MD
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Telephone | 502-893-7372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 36325
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License Number State | KY
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