Basic Information
| Provider Information | |||||||||
| NPI: | 1679570675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLINS | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N EAGLE CREEK DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N EAGLE CREEK DR STE 500 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 17380 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207W00000X | 17380 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 17380 | KY | Y |
ID Information
| ID | Type | State | Issuer | Description | 1679570675 | 05 | WV | MEDICAID | 000000048591 | 01 | KY | ANTHEM PROVIDER NUMBER | OTHER | 0685503 | 05 | OH | MEDICAID | 64173800 | 05 | KY | MEDICAID | 611246763 | 01 | KY | TAX ID | OTHER | 300027596 | 05 | IN | MEDICAID |