Todd E Bullock, APRN
Individual provider Active NPI Family Nurse Practitioner · Caneyville, KY
NPI 1104822360 · NPPES record last updated Nov 14, 2018
Key facts
- NPI
- 1104822360
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 3004076 (KY)
- Practice address
- 301 Sunset Dr
Caneyville, KY 42721-9172 - Phone
- (270) 879-3711
- Fax
- (270) 879-8674
- NPI assigned
- Jun 22, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 18
Hospital & facility affiliations 5
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2003
- Medicare assignment
- May accept Medicare assignment
- Group practices
- PT Pros, Inc
Owensboro Health Twin Lakes Regional Medical Center, Inc
Practice addresses (Care Compare)
201 S Main St
Leitchfield, KY 42754-1425
Phone (270) 230-1729
301 Sunset Dr
Caneyville, KY 42721-9172
Phone (270) 879-3711
Hospital & facility affiliations
- Twin Lakes Home Health
- Family Home Health Care, LLC Dba Adoration Home Health
- Centerwell Home Health
- Owensboro Health Regional Hospital
- Owensboro Health Twin Lakes Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in KY
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100913000881 | KY | Practitioner - Nurse Practitioner | 4385769462 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Owensboro Health Twin Lakes Regional Medical Center, Inc | Current |
Accepting new patients |
Locations
25516 Network Pl
Chicago, IL 60673
301 Sunset Dr
Caneyville, KY 42721
Phone (270) 879-3711
910 Wallace Ave
Leitchfield, KY 42754
Phone (270) 259-3035
Interoperability endpoints
- tbullock40297@direct.owensborohealth.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 3004076 | KY | Yes |
Addresses
Primary practice location
301 Sunset Dr
Caneyville, KY 42721-9172
Mailing address
908 Wallace Ave
Leitchfield, KY 42754-1479
Phone (270) 259-1626
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000302145 | Other | KY | ANTHEM |
| 2443164000 | Other | KY | PASSPORT ADVANTAGE |
| 50001589 | Other | KY | PASSPORT |
| 78010436 | Medicaid | KY |
NPI Registry JSON
{
"created_epoch": "1119398400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1542153600000",
"number": "1104822360",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "908 WALLACE AVE",
"city": "LEITCHFIELD",
"state": "KY",
"postal_code": "427541479",
"telephone_number": "270-259-1626",
"fax_number": "270-259-9582"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "301 SUNSET DR",
"city": "CANEYVILLE",
"state": "KY",
"postal_code": "427219172",
"telephone_number": "270-879-3711",
"fax_number": "270-879-8674"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BULLOCK",
"first_name": "TODD",
"middle_name": "E",
"credential": "APRN",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-06-22",
"last_updated": "2018-11-14",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "KY",
"license": "3004076",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM",
"identifier": "000000302145",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PASSPORT ADVANTAGE",
"identifier": "2443164000",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PASSPORT",
"identifier": "50001589",
"state": "KY"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "78010436",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Caneyville, KY
- Bluegrass Occupational & Environmental Health Consulting LLC
- Kelly Ann Decker
- Embry Medical Supply
- Embry Welding Supply Inc
- Martha Gary
- Andrea H. Gay
All providers in Caneyville, KY · Family Nurse Practitioner in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 14, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.