1982879888 NPI number — EASTERN KY CENTER FOR PLASTIC, RECONSTRUCTIVE & COSMETIC SURGERY

Table of content: (NPI 1982879888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982879888 NPI number — EASTERN KY CENTER FOR PLASTIC, RECONSTRUCTIVE & COSMETIC SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN KY CENTER FOR PLASTIC, RECONSTRUCTIVE & COSMETIC SURGERY
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:
6
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:
1982879888
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2257
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-432-0061
Provider Business Mailing Address Fax Number:
606-432-0095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 TRIVETTE DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PIKEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41501-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-432-0061
Provider Business Practice Location Address Fax Number:
606-432-0095
Provider Enumeration Date:
04/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LU
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LYN T.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-432-0061

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64256423 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0114191000 . This is a "WV MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1532903 . This is a "UMWA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000051790 . This is a "BC/BS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 240005992 . This is a "R/R MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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