Basic Information
| Provider Information | |||||||||
| NPI: | 1801897855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, FASAM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 222 PHILLIP STONE WAY | ||||||||
| Address2: | |||||||||
| City: | CENTRAL CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423301929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707543494 | ||||||||
| FaxNumber: | 2707543494 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PHILLIP STONE WAY | ||||||||
| Address2: | |||||||||
| City: | CENTRAL CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423301929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707543494 | ||||||||
| FaxNumber: | 2707543499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36099 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 36099 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64017379 | 05 | KY | MEDICAID |