Provider Demographics
NPI:1356499602
Name:LEXINGTON DIABETIC CENTER PSC
Entity Type:Organization
Organization Name:LEXINGTON DIABETIC CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-977-8855
Mailing Address - Street 1:3292 EAGLE VIEW LN
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2173
Mailing Address - Country:US
Mailing Address - Phone:859-977-8855
Mailing Address - Fax:859-977-8856
Practice Address - Street 1:3292 EAGLE VIEW LN
Practice Address - Street 2:SUITE 210
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2173
Practice Address - Country:US
Practice Address - Phone:859-977-8855
Practice Address - Fax:859-977-8856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39043305S00000X
KY363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00404838OtherTG LDC RAILROAD PIN
KY64313646Medicaid
KY1285781682OtherTOSHA NPI
KY64094485Medicaid
KYDD2844OtherTG LDC RR GRP
KY65946022Medicaid
000000545010OtherTG ANTHEM LDC
KY9491Medicare ID - Type UnspecifiedMEDICARE GROUP
KY64094485Medicaid
KY65946022Medicaid
KY64313646Medicaid