1285776476 NPI number — SOUTHERN KENTUCKY EYE CENTER PSC

Table of content: (NPI 1285776476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285776476 NPI number — SOUTHERN KENTUCKY EYE CENTER PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN KENTUCKY EYE CENTER PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285776476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 TRADEPARK DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42503-3454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-679-7778
Provider Business Mailing Address Fax Number:
606-451-1814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 TRADEPARK DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503-3454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-679-7778
Provider Business Practice Location Address Fax Number:
606-451-1814
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOMER
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING DEPT MANAGER
Authorized Official Telephone Number:
606-679-5837

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3061400 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4020794 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1520956 . This is a "UMWA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 65928939 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000041743 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 180028760 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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