Provider Demographics
NPI:1366407447
Name:SKANDAMIS, KONSTANTINOS G (MD)
Entity type:Individual
Prefix:
First Name:KONSTANTINOS
Middle Name:G
Last Name:SKANDAMIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
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:502-272-5116
Practice Address - Street 1:1930 BISHOP LN
Practice Address - Street 2:STE 1600
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1921
Practice Address - Country:US
Practice Address - Phone:502-272-5100
Practice Address - Fax:502-272-5116
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY38006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200505860Medicaid
KY13219442OtherCHA- NORTON ICC
KYP00293208OtherRAILROAD MEDICARE
KY000000382368OtherANTHEM
KY200505860OtherHEALTHY INDIANA PLAN- NORTON ICC
KYP00305292OtherRAILROAD MEDICARE
KY047513OtherSIHO
IN200505860OtherANTHEM INDIANA MEDICAID- NORTON ICC
KY200505860OtherMD WISE- NORTON IMMEDIATE CARE CENTER
KY13219442OtherCHA- NORTON ICC
KY200505860OtherMD WISE- NORTON IMMEDIATE CARE CENTER
A82039Medicare UPIN