Basic Information
| Provider Information | |||||||||
| NPI: | 1043255201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRIMM | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | DEATON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | K401 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235533 | ||||||||
| FaxNumber: | 8593232412 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 S LIMESTONE | ||||||||
| Address2: | K401 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235533 | ||||||||
| FaxNumber: | 8593232412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | 19618 | KY | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 207X00000X | 19618 | KY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | D82696 | 01 | KY | UPIN | OTHER | 64196181 | 05 | KY | MEDICAID |