Healthcare Provider Details

I. General information

NPI: 1396823381
Provider Name (Legal Business Name): HEAD AND NECK SURGERY ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7575 US 42
FLORENCE KY
41042-1939
US

IV. Provider business mailing address

40 N GRAND AVE STE 103
FORT THOMAS KY
41075-1771
US

V. Phone/Fax

Practice location:
  • Phone: 859-781-4900
  • Fax: 859-572-3035
Mailing address:
  • Phone: 859-781-4900
  • Fax: 859-572-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number300097
License Number StateKY

VIII. Authorized Official

Name: JESSICA DETRICK
Title or Position: COO
Credential:
Phone: 859-572-4104