Provider Demographics
NPI:1902140791
Name:CARDIOVASCULAR CONSULTANTS OF KENTUCKY, LLC
Entity Type:Organization
Organization Name:CARDIOVASCULAR CONSULTANTS OF KENTUCKY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHOTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-744-0263
Mailing Address - Street 1:191 WAL MART WAY
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-7518
Mailing Address - Country:US
Mailing Address - Phone:859-744-0263
Mailing Address - Fax:859-745-0836
Practice Address - Street 1:191 WAL MART WAY
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-7518
Practice Address - Country:US
Practice Address - Phone:859-744-0263
Practice Address - Fax:859-745-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35596207RC0000X
KYPA562363A00000X
KY3007563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100240350Medicaid
OH0078741Medicaid
KYK091640Medicare PIN