Basic Information
Provider Information | |||||||||
NPI: | 1467564054 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENTUCKY EYE INSTITUTE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 PERIMETER DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LEXINGTON | ||||||||
State: | KY | ||||||||
PostalCode: | 405174121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592789393 | ||||||||
FaxNumber: | 8592780923 | ||||||||
Practice Location | |||||||||
Address1: | 65 E CITY DAM RD | ||||||||
Address2: |   | ||||||||
City: | CORBIN | ||||||||
State: | KY | ||||||||
PostalCode: | 407014620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592789393 | ||||||||
FaxNumber: | 8592780923 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 05/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MYERS | ||||||||
AuthorizedOfficialFirstName: | ARIC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8592789393 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 31282 | KY | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 7100226610 | 05 | KY |   | MEDICAID |