Provider Demographics
NPI:1255582755
Name:INTERNAL MEDICINE CONSULTANTS, PLLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:POLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-629-4525
Mailing Address - Street 1:234 E GRAY ST STE 670
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1901
Mailing Address - Country:US
Mailing Address - Phone:502-629-4525
Mailing Address - Fax:502-629-4529
Practice Address - Street 1:234 E GRAY ST STE 670
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1901
Practice Address - Country:US
Practice Address - Phone:502-629-4525
Practice Address - Fax:502-629-4529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
KY3008115363LF0000X
KY36067207R00000X
KY3006356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1128116OtherPAAAPORT
KY1952399669Medicare NSC