Basic Information
| Provider Information | |||||||||
| NPI: | 1740253194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH KENTUCKY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 WILHITE DR | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405033385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592751922 | ||||||||
| FaxNumber: | 8592253154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 36D1093279 | OH | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 291U00000X | 18D0648517 | KY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 37900032 | 05 | KY | MEDICAID | 6701090000 | 05 | WV | MEDICAID | 3047983 | 05 | OH | MEDICAID | 010231078 | 05 | VA | MEDICAID |