Healthcare Provider Details

I. General information

NPI: 1508971722
Provider Name (Legal Business Name): BUFFALO TRACE GASTROENTEROLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 MEDICAL PARK DR STE 203
MAYSVILLE KY
41056-8728
US

IV. Provider business mailing address

991 MEDICAL PARK DR STE 203
MAYSVILLE KY
41056-8728
US

V. Phone/Fax

Practice location:
  • Phone: 606-759-5157
  • Fax: 606-759-5582
Mailing address:
  • Phone: 606-759-5157
  • Fax: 606-759-5582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number34725
License Number StateKY

VIII. Authorized Official

Name: MS. KAMI JARRELLS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 606-759-4869