Healthcare Provider Details

I. General information

NPI: 1710982517
Provider Name (Legal Business Name): MICHAEL KEITH DAVENPORT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR STE 254
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-1600
  • Fax: 859-344-0091
Mailing address:
  • Phone: 859-344-1600
  • Fax: 859-344-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number32327
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: