MEDICARE: KIOSK MEDICINE KENTUCKY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376966358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIOSK MEDICINE KENTUCKY LLC

Provider Business Mailing Address
First Line	:	PO BOX 932958
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44193-0028
Country	:	US
Telephone Number	:	615-425-4200
Fax Number	:	615-425-4201

Provider Business Practice Location Address
First Line	:	2150 DIXIE HWY
Second Line	:
City	:	FORT MITCHELL
State	:	KY
Zip	:	41017-2902
Country	:	US
Telephone Number	:	859-292-1784
Fax Number	:	859-292-1785

Authorized Official
Title or Position	:	VP & GENERAL MANAGER
Name	:	MR. THOMAS SHELLY
Credential	:
Telephone Number	:	615-425-4200

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	10/21/2025

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