Basic Information
| Provider Information | |||||||||
| NPI: | 1396724092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH LEXINGTON URGENT TREATMENT ASSOCIATES PSC | ||||||||
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| OtherOrganizationName: | URGENT TREATMENT CLINICS UTC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 DOVE RUN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405023536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592680061 | ||||||||
| FaxNumber: | 8592661152 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 DOVE RUN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405023536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592694668 | ||||||||
| FaxNumber: | 8592665577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 05/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | BACHA | ||||||||
| AuthorizedOfficialFirstName: | FADI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8592694668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100041440 | 05 | KY | MEDICAID | 78903945 | 05 | KY | MEDICAID | 65935736 | 05 | KY | MEDICAID |