Healthcare Provider Details

I. General information

NPI: 1770741498
Provider Name (Legal Business Name): COMMONWEALTH SPECIALISTS OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 KINGS DAUGHTERS DR SUITE 308
FRANKFORT KY
40601-6514
US

IV. Provider business mailing address

279 KINGS DAUGHTERS DR SUITE 100
FRANKFORT KY
40601-6514
US

V. Phone/Fax

Practice location:
  • Phone: 502-352-2530
  • Fax:
Mailing address:
  • Phone: 502-352-2530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number34
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number19
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number19
License Number StateKY
# 7
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TEDRICK JOHNSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 502-352-2530