Provider Demographics
| NPI: | 1306983762 |
|---|---|
| Name: | COMMUNITY MEDICAL ASSOCIATES, INC. |
| Entity type: | Organization |
| Organization Name: | COMMUNITY MEDICAL ASSOCIATES, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VP MANAGED CARE |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | SHELLEY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | GAST |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 502-588-9490 |
| Mailing Address - Street 1: | PO BOX 776351 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHICAGO |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 60677-6351 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 502-588-9490 |
| Mailing Address - Fax: | 502-272-5339 |
| Practice Address - Street 1: | 4803 OLYMPIA PARK PLZ STE 1100 |
| Practice Address - Street 2: | |
| Practice Address - City: | LOUISVILLE |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 40241-3068 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 502-588-9490 |
| Practice Address - Fax: | 502-272-5116 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-02-01 |
| Last Update Date: | 2023-04-03 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
| No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
| No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | Group - Multi-Specialty |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IN | 1003882650 | Medicaid | |
| KY | 65946279 | Medicaid | |
| KY | 65945693 | Medicaid | |
| KY | 65945693 | Medicaid | |
| KY | CC9492 | Medicare PIN | |
| IN | 1003882650 | Medicaid | |
| KY | 3619 | Medicare PIN | |
| IN | CD5379 | Other | RAILROAD MEDICARE |
