Basic Information
| Provider Information | |||||||||
| NPI: | 1356817274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY MEDICAL SERVICES FOUNDATION, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | UK HEALTHCARE MEDICAL STAFF AFFAIRS | ||||||||
| Address2: | 740 S. LIMESTONE K005Q | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405360284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593232374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 845 ANGLIANA AVE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593239321 | ||||||||
| FaxNumber: | 8592575232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2018 | ||||||||
| LastUpdateDate: | 10/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | MARCUS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHROIZED OFFICIAL, CHAIR, DEPARTM | ||||||||
| AuthorizedOfficialTelephone: | 8592577618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KENTUCKY MEDICAL SERVICES FOUNDATION, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 175T00000X | N | 193200000X MULTI-SPECIALTY GROUP | 2084A0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.