Basic Information
| Provider Information | |||||||||
| NPI: | 1023053147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEELEY | ||||||||
| FirstName: | ELLSWORTH | ||||||||
| MiddleName: | CARL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | K-302 KENTUCKY CLINIC | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236711 | ||||||||
| FaxNumber: | 8593236661 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | K-302 KENTUCKY CLINIC | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236711 | ||||||||
| FaxNumber: | 8593236661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | 10512 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0401X | 10512 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207QA0505X | 10512 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207QG0300X | 10512 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | 10512 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 10512 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64105125 | 05 | KY | MEDICAID |