Healthcare Provider Details

I. General information

NPI: 1255735346
Provider Name (Legal Business Name): TAS OF KENTUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 MEDICAL CENTER CIR
MAYFIELD KY
42066-1159
US

IV. Provider business mailing address

PO BOX 2416
LEESBURG VA
20177-7703
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateKY

VIII. Authorized Official

Name: JUSTIN SMITH
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 703-727-3462