Healthcare Provider Details

I. General information

NPI: 1770574790
Provider Name (Legal Business Name): EUGENE C FLETCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 GOSHEN LN
GOSHEN KY
40026-9509
US

IV. Provider business mailing address

1600 GOSHEN LN
GOSHEN KY
40026-9509
US

V. Phone/Fax

Practice location:
  • Phone: 502-228-2636
  • Fax:
Mailing address:
  • Phone: 520-228-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01046080A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number29686
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01046080A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number29686
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: