Provider Demographics
NPI:1063293389
Name:KIOSK MEDICINE OF KENTUCKY LLC
Entity type:Organization
Organization Name:KIOSK MEDICINE OF KENTUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-425-4200
Mailing Address - Street 1:PO BOX 932958
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0028
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:615-425-4201
Practice Address - Street 1:2835 S HIGHWAY 393
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9613
Practice Address - Country:US
Practice Address - Phone:502-530-4812
Practice Address - Fax:502-530-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100949580Medicaid