Healthcare Provider Details

I. General information

NPI: 1508101460
Provider Name (Legal Business Name): KENTUCKY MSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 LEXINGTON RD SUITE 230
GEORGETOWN KY
40324-9672
US

IV. Provider business mailing address

1138 LEXINGTON RD SUITE 230
GEORGETOWN KY
40324-9672
US

V. Phone/Fax

Practice location:
  • Phone: 502-570-3727
  • Fax: 502-570-3753
Mailing address:
  • Phone: 502-570-3727
  • Fax: 502-570-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY D VAUGHN
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-372-8500