Basic Information
| Provider Information | |||||||||
| NPI: | 1114973146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPITAL SURGICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406014107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022237629 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PHYSICIANS PARK | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406014107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022237629 | ||||||||
| FaxNumber: | 5022239829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | VALLANCE | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5022237629 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 65903767 | 05 | KY | MEDICAID |