Healthcare Provider Details

I. General information

NPI: 1902164411
Provider Name (Legal Business Name): VINCENT PRUSICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CONN TER
LEXINGTON KY
40508
US

IV. Provider business mailing address

110 CONN TER
LEXINGTON KY
40508-3206
US

V. Phone/Fax

Practice location:
  • Phone: 586-268-5741
  • Fax:
Mailing address:
  • Phone: 859-268-5622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number56224
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number51561
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: