Healthcare Provider Details

I. General information

NPI: 1336483957
Provider Name (Legal Business Name): KENTUCKY MSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 LEXINGTON RD SUITE 202
GEORGETOWN KY
40324-9330
US

IV. Provider business mailing address

1140 LEXINGTON RD SUITE 202
GEORGETOWN KY
40324-9330
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-5603
  • Fax: 502-868-5612
Mailing address:
  • Phone: 502-868-5603
  • Fax: 502-868-5612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: KATHY TEAGUE
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 615-920-7000