=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922262179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON PURCHASE PULMONARY MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2008
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 MEDICAL CENTER CIR
-----------------------------------------------------
City | MAYFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42066-1194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-650-7163
-----------------------------------------------------
Fax | 855-430-0335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 MEDICAL CENTER CIR
-----------------------------------------------------
City | MAYFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42066-1194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-251-4040
-----------------------------------------------------
Fax | 855-430-0335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERTO DOS REMEDIOS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 270-933-7823
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 3010022
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | 40940
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------