Healthcare Provider Details

I. General information

NPI: 1699137604
Provider Name (Legal Business Name): ALEXANDER GOODSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 07/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF KENTUCKY 800 ROSE STREET
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

UNIVERSITY OF KENTUCKY 800 ROSE STREET
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-2636
  • Fax:
Mailing address:
  • Phone: 859-323-6762
  • Fax: 859-323-1315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR4074
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: