Basic Information
| Provider Information | |||||||||
| NPI: | 1881636470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENTUCKY INSTITUTE FOR EYE HEALTH & SURGERY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENTUCKY EYE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 PERIMETER DR | ||||||||
| Address2: | STE 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: | 06/11/2006 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | ARIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8592789393 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | COO | ||||||||
| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 32182 | 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 | 65912479 | 05 | KY | MEDICAID |