Provider Demographics
NPI:1003026295
Name:THACKER, JEREMY WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WAYNE
Last Name:THACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:HX316
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0293
Mailing Address - Country:US
Mailing Address - Phone:859-948-7773
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:HX-302 UKMC
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0293
Practice Address - Country:US
Practice Address - Phone:859-257-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY417472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100097180Medicaid
KYK058560Medicare PIN