Provider Demographics
NPI:1396823381
Name:HEAD AND NECK SURGERY ASSOCIATES, PSC
Entity Type:Organization
Organization Name:HEAD AND NECK SURGERY ASSOCIATES, PSC
Other - Org Name:CENTER FOR SURGICAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-572-4104
Mailing Address - Street 1:40 N GRAND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1771
Mailing Address - Country:US
Mailing Address - Phone:859-781-4900
Mailing Address - Fax:859-572-3039
Practice Address - Street 1:7575 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1939
Practice Address - Country:US
Practice Address - Phone:859-781-4900
Practice Address - Fax:859-572-3035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEAD AND NECK SURGERY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300097261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
6800084OtherUNITED HEALTHCARE
KY300097OtherKY LICENSE
490002867OtherMEDICARE RR
000000198567OtherANTHEM
KY36000735Medicaid
490002867OtherMEDICARE RR
KYASC 1024Medicare ID - Type UnspecifiedKY MEDICARE GROUP NUMBER