Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2084P0800X | Psychiatry & Neurology | Psychiatry | 26656 | KENTUCKY | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 160780 | OTHER | INDIANA | MEDICARE GROUP |
| 2 | 41051000 | OTHER | | MAGELLAN MIS |
| 3 | 64266562 | MEDICAID | KENTUCKY | |
| 4 | P00204278 | OTHER | INDIANA | RAILROAD MEDICARE |
| 5 | 6764 | OTHER | KENTUCKY | MEDICARE GROUP |
| 6 | 78903689 | OTHER | KENTUCKY | MEDICAID GROUP |
| 7 | 100386460 | OTHER | INDIANA | MEDICAID GROUP |
| 8 | 50704000 | OTHER | | MAGELLAN GROUP |
| 9 | P00639807 | OTHER | KENTUCKY | RAILROAD MEDICARE |
| 10 | 000000056294 | OTHER | | ANTHEM GROUP |
| 11 | 000000344393 | OTHER | | ANTHEM ID # |
| 12 | 100362960A | MEDICAID | INDIANA | |
| 13 | 1063415297 | OTHER | | GROUP NPI |
| 14 | 160860 | OTHER | INDIANA | MEDICARE GROUP |
| 15 | 2444451000 | OTHER | KENTUCKY | PASSPORT ADVANTAGE GROUP |
| 16 | 2703588000 | OTHER | KENTUCKY | PASSPORT ADVANTAGE |
| 17 | 65927857 | OTHER | KENTUCKY | MEDICAID GROUP |
| 18 | 82900176 | OTHER | KENTUCKY | MEDICAID GROUP |
| 19 | CG3623 | OTHER | INDIANA | RAILROAD MEDICARE GROUP |
| 20 | CK2274 | OTHER | KENTUCKY | RAILROAD MEDICARE GROUP |
