=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588057897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIOSK MEDICINE OF KENTUCKY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2015
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 W JOHN ROWAN BLVD
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-2663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-348-7880
-----------------------------------------------------
Fax | 502-348-7881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 932958
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44193-0028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-425-4200
-----------------------------------------------------
Fax | 615-425-4201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP & GENERAL MANAGER
-----------------------------------------------------
Name | MR. THOMAS SHELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-425-4287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------