Healthcare Provider Details

I. General information

NPI: 1306020979
Provider Name (Legal Business Name): LEE W RICKETTS II MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1782 BRYAN STATION ROAD
LEXINGTON KY
40505
US

IV. Provider business mailing address

1782 BRYAN STATION ROAD
LEXINGTON KY
40505
US

V. Phone/Fax

Practice location:
  • Phone: 859-294-0077
  • Fax: 859-294-0078
Mailing address:
  • Phone: 859-294-0077
  • Fax: 859-294-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30881
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30881
License Number StateKY

VIII. Authorized Official

Name: MR. LEE W RICKETTS II
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 859-294-0077