Provider Demographics
NPI:1326181728
Name:KENTUCKY SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:KENTUCKY SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:MACHAL
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-268-0268
Mailing Address - Street 1:601 PERIMETER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4121
Mailing Address - Country:US
Mailing Address - Phone:859-268-0268
Mailing Address - Fax:859-268-4519
Practice Address - Street 1:601 PERIMETER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4121
Practice Address - Country:US
Practice Address - Phone:859-268-0268
Practice Address - Fax:859-268-4519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65939795Medicaid
KYCM6945OtherGROUP RAILROAD MEDICARE #
KY=========00OtherGROUP OWCP NUMBER
KY=========00OtherGROUP OWCP NUMBER