Healthcare Provider Details

I. General information

NPI: 1790711323
Provider Name (Legal Business Name): CENTRAL KENTUCKY ORTHOPAEDICS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WINDSOR PATH SUITE 1
GEORGETOWN KY
40324-9617
US

IV. Provider business mailing address

101 WINDSOR PATH SUITE 1
GEORGETOWN KY
40324-9617
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-6106
  • Fax: 502-868-6107
Mailing address:
  • Phone: 502-868-6106
  • Fax: 502-868-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number37293
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY C WILSON
Title or Position: OWNER
Credential: M.D.
Phone: 502-868-6106