MEDICARE: NORTHERN KENTUCKY PSYCHIATRY ASSOC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	2084P0800X	Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5796	OTHER	KY	ANTHEM
2	079122000	OTHER	KY	MAGELLAN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437108099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN KENTUCKY PSYCHIATRY ASSOC

Provider Business Mailing Address
First Line	:	2380 GRANDVIEW DR
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41017-1633
Country	:	US
Telephone Number	:	859-331-7234
Fax Number	:	859-578-7986

Provider Business Practice Location Address
First Line	:	2380 GRANDVIEW DR
Second Line	:
City	:	FT MITCHELL
State	:	KY
Zip	:	41017-1633
Country	:	US
Telephone Number	:	859-331-7234
Fax Number	:	859-578-7986

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AGUSTINA A. BALUYOT
Credential	:	M.D.
Telephone Number	:	859-331-7234

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	12/04/2014

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