Provider Demographics
NPI:1003369216
Name:CRESTVIEW HILLS SURGERY CENTER, PLLC
Entity Type:Organization
Organization Name:CRESTVIEW HILLS SURGERY CENTER, PLLC
Other - Org Name:ICAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-957-0700
Mailing Address - Street 1:210 THOMAS MORE PKWY UPPR LEVEL
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3429
Mailing Address - Country:US
Mailing Address - Phone:859-331-4555
Mailing Address - Fax:859-331-6555
Practice Address - Street 1:210 THOMAS MORE PKWY UPPR LEVEL
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3429
Practice Address - Country:US
Practice Address - Phone:859-331-4555
Practice Address - Fax:859-331-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2838808Medicaid
KY64311541Medicaid
KY64311541Medicaid