Healthcare Provider Details

I. General information

NPI: 1164795233
Provider Name (Legal Business Name): BAPTIST FAMILY MEDICINE AT TATES CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4071 TATES CREEK CENTRE DRIVE SUITE 202
LEXINGTON KY
40517
US

IV. Provider business mailing address

4071 TATES CREEK CENTRE DRIVE SUITE 202
LEXINGTON KY
40517
US

V. Phone/Fax

Practice location:
  • Phone: 859-273-3888
  • Fax: 859-971-4601
Mailing address:
  • Phone: 859-273-3888
  • Fax: 859-971-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3002500
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL FLECKINSTEIN
Title or Position: REVENUE CYCLE DIRECTOR
Credential:
Phone: 859-971-4633