Healthcare Provider Details

I. General information

NPI: 1164867883
Provider Name (Legal Business Name): KENTUCKY MSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 LEXINGTON RD SUITE 140
GEORGETOWN KY
40324-9672
US

IV. Provider business mailing address

1138 LEXINGTON RD SUITE 140
GEORGETOWN KY
40324-9672
US

V. Phone/Fax

Practice location:
  • Phone: 502-570-3721
  • Fax: 502-570-3722
Mailing address:
  • Phone: 502-570-3721
  • Fax: 502-570-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MONICA BOWMAN
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 615-920-7000