Provider Demographics
NPI:1093818551
Name:KIRTI K JAIN, MD PSC
Entity type:Organization
Organization Name:KIRTI K JAIN, MD PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRTI
Authorized Official - Middle Name:K
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-836-0202
Mailing Address - Street 1:122 SAINT CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7016
Mailing Address - Country:US
Mailing Address - Phone:606-836-7377
Mailing Address - Fax:606-836-2189
Practice Address - Street 1:4958 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-0999
Practice Address - Fax:606-886-2886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5700P363L00000X
KYTP5342085R0001X
KY23276207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65939043Medicaid
KY3780Medicare ID - Type UnspecifiedGROUP NUMBER