Basic Information
| Provider Information | |||||||||
| NPI: | 1598820037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KENTUCKY EAR, NOSE & THROAT, P.S.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENTUCKY EAR, NOSE & THROAT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 NICHOLASVILLE RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592781114 | ||||||||
| FaxNumber: | 8592783774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 NICHOLASVILLE RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592781114 | ||||||||
| FaxNumber: | 8592783774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RANDOLPH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8592781114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | CI8554 | 01 | RAILROAD MEDICARE ID | OTHER |