Healthcare Provider Details

I. General information

NPI: 1114079555
Provider Name (Legal Business Name): CENTRAL KENTUCKY SURGEONS, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DANIEL DR
DANVILLE KY
40422-2527
US

IV. Provider business mailing address

130 DANIEL DR
DANVILLE KY
40422-2527
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-2222
  • Fax: 859-236-2227
Mailing address:
  • Phone: 859-236-2222
  • Fax: 859-236-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN H. LACY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 859-236-2222