=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881874592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN KENTUCKY KIDNEY CARE, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2007
-----------------------------------------------------
Last Update Date | 02/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 WEDDINGTON BRANCH RD
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41501-3204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-437-0662
-----------------------------------------------------
Fax | 606-437-0618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2144
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41502-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-437-0662
-----------------------------------------------------
Fax | 606-437-0618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | MR. KASSAW A JOSEPH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 606-437-0662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | TP610
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------