Provider Demographics
NPI:1538600630
Name:CLEANSLATE MEDICAL GROUP OF KENTUCKY PLLC
Entity type:Organization
Organization Name:CLEANSLATE MEDICAL GROUP OF KENTUCKY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:SMOLAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-999-5188
Mailing Address - Street 1:8 CADILLAC DR STE 180
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5393
Mailing Address - Country:US
Mailing Address - Phone:154-250-0220
Mailing Address - Fax:833-279-7074
Practice Address - Street 1:6801 DIXIE HWY STE 132
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3952
Practice Address - Country:US
Practice Address - Phone:502-657-2701
Practice Address - Fax:833-279-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty