Provider Demographics
NPI:1083655708
Name:SCULLY, KEVIN T (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:SCULLY
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 1:1720 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1475
Mailing Address - Country:US
Mailing Address - Phone:859-277-5887
Mailing Address - Fax:859-276-7638
Practice Address - Street 1:1720 NICHOLASVILLE RD STE 400
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1475
Practice Address - Country:US
Practice Address - Phone:859-277-5887
Practice Address - Fax:859-276-7638
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22190207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6422190600Medicaid
KY060019842OtherRAILROAD MEDICARE
KY6422190600Medicaid