Basic Information
| Provider Information | |||||||||
| NPI: | 1316072432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENTUCKY URGENT TREATMENT ASSOCIATES, PSC | ||||||||
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| OtherOrganizationName: | NICHOLASVILLE URGENT TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3174 CUSTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592738882 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 BELLAIRE DRIVE | ||||||||
| Address2: | |||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598874882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8592738882 | ||||||||
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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 | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65946105 | 05 | KY | MEDICAID |