Provider Demographics
NPI:1043697477
Name:RAINES, SELENA G (DO)
Entity Type:Individual
Prefix:
First Name:SELENA
Middle Name:G
Last Name:RAINES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1077
Mailing Address - Country:US
Mailing Address - Phone:606-780-5311
Mailing Address - Fax:606-780-2362
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-783-7281
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100497270Medicaid