Provider Demographics
NPI:1306020979
Name:LEE W RICKETTS II MD PLLC
Entity Type:Organization
Organization Name:LEE W RICKETTS II MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:859-294-0077
Mailing Address - Street 1:1782 BRYAN STATION ROAD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505
Mailing Address - Country:US
Mailing Address - Phone:859-294-0077
Mailing Address - Fax:859-294-0078
Practice Address - Street 1:1782 BRYAN STATION ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505
Practice Address - Country:US
Practice Address - Phone:859-294-0077
Practice Address - Fax:859-294-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30881207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000308817OtherANTHEM
KY0791601OtherMEDICARE INDIVIDUAL
KY64308810Medicaid
KY64308810Medicaid
KY7916Medicare PIN