=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619165644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY CARDIOVASCULAR CONSULTANTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 09/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 E PARRISH AVE BLDG B, LL103
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-926-2998
-----------------------------------------------------
Fax | 270-852-1653
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 E PARRISH AVE BLDG B, LL103
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42303-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-926-2998
-----------------------------------------------------
Fax | 270-852-1653
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OF CORPORATION
-----------------------------------------------------
Name | DR. MUKESH GUPTA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 270-926-2998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 32463
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------