Basic Information
| Provider Information | |||||||||
| NPI: | 1295948164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENTUCKY INSTITUTE FOR EYE HEALTH AND SURGERY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KY EYE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | B75 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592789393 | ||||||||
| FaxNumber: | 8592780923 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 HARRODSBURG RD | ||||||||
| Address2: | B75 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592789393 | ||||||||
| FaxNumber: | 8592780923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOODWORTH | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8592789393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 65912776 | 05 | KY | MEDICAID | 65922288 | 05 | KY | MEDICAID | 65937435 | 05 | KY | MEDICAID | 65912479 | 05 | KY | MEDICAID | 65912529 | 05 | KY | MEDICAID | 65912461 | 05 | KY | MEDICAID | 77903540 | 05 | KY | MEDICAID | 65912511 | 05 | KY | MEDICAID |