Healthcare Provider Details

I. General information

NPI: 1790771046
Provider Name (Legal Business Name): MILLARD LYNN FOGLEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 QUEENDALE CTR RED BIRD CLINIC
BEVERLY KY
40913-9607
US

IV. Provider business mailing address

53 QUEENDALE CTR RED BIRD CLINIC
BEVERLY KY
40913-9607
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5135
  • Fax: 606-598-8942
Mailing address:
  • Phone: 606-598-5135
  • Fax: 606-598-8942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33564
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: