=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558954776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY HOSPITALIST GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2021
-----------------------------------------------------
Last Update Date | 03/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3117 AYLESBURY CIR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-948-8430
-----------------------------------------------------
Fax | 859-744-3095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3117 AYLESBURY CIR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-948-8430
-----------------------------------------------------
Fax | 859-744-3095
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING AGENT
-----------------------------------------------------
Name | DEBI CAREY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-576-9895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------