Provider Demographics
NPI:1215936240
Name:NEUROSCIENCE ASSOCIATES OF NORTHERN KENTUCKY PSC
Entity type:Organization
Organization Name:NEUROSCIENCE ASSOCIATES OF NORTHERN KENTUCKY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-3412
Mailing Address - Street 1:2845 CHANCELLOR DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3418
Mailing Address - Country:US
Mailing Address - Phone:859-341-3412
Mailing Address - Fax:859-341-3171
Practice Address - Street 1:2845 CHANCELLOR DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3452
Practice Address - Country:US
Practice Address - Phone:859-341-3412
Practice Address - Fax:859-341-3171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1096049363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933947Medicaid
KY6081204000OtherDOL
KYDF1983OtherRAILROAD MEDICARE
KYDF1983OtherRAILROAD MEDICARE