Healthcare Provider Details

I. General information

NPI: 1598820037
Provider Name (Legal Business Name): CENTRAL KENTUCKY EAR, NOSE & THROAT, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 NICHOLASVILLE RD SUITE 500
LEXINGTON KY
40503-1404
US

IV. Provider business mailing address

1720 NICHOLASVILLE RD SUITE 500
LEXINGTON KY
40503-1404
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-1114
  • Fax: 859-278-3774
Mailing address:
  • Phone: 859-278-1114
  • Fax: 859-278-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN RANDOLPH
Title or Position: PRACTICE ADMINISTRATOR
Credential: CPA
Phone: 859-278-1114