Provider Demographics
NPI:1215962212
Name:KENTUCKIANA HEART & VASCULAR SPECIALISTS PSC
Entity type:Organization
Organization Name:KENTUCKIANA HEART & VASCULAR SPECIALISTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-926-2998
Mailing Address - Street 1:815 EAST PARRISH AVENUE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303
Mailing Address - Country:US
Mailing Address - Phone:270-926-2998
Mailing Address - Fax:270-926-1181
Practice Address - Street 1:815 EAST PARRISH AVENUE
Practice Address - Street 2:SUITE 330
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303
Practice Address - Country:US
Practice Address - Phone:270-926-2998
Practice Address - Fax:270-926-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65909848Medicaid
8807Medicare ID - Type Unspecified