=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598020075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASIK ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2012
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MEDICAL CENTER DR
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42003-7909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-442-1671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1903 BROADWAY ST
-----------------------------------------------------
City | PADUCAH
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42001-7105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-442-1671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. MARK GILLESPIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-442-1671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0132X
-----------------------------------------------------
Taxonomy Name | Ophthalmologic Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------