Provider Demographics
NPI:1417224585
Name:KENTUCKY MSO LLC
Entity Type:Organization
Organization Name:KENTUCKY MSO LLC
Other - Org Name:STAMPING GROUND - GEORGETOWN FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESS
Authorized Official - Middle Name:N
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:3501 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STAMPING GROUND
Mailing Address - State:KY
Mailing Address - Zip Code:40379-9631
Mailing Address - Country:US
Mailing Address - Phone:502-535-5686
Mailing Address - Fax:502-535-5585
Practice Address - Street 1:3501 MAIN ST
Practice Address - Street 2:
Practice Address - City:STAMPING GROUND
Practice Address - State:KY
Practice Address - Zip Code:40379-9631
Practice Address - Country:US
Practice Address - Phone:502-535-5686
Practice Address - Fax:502-535-5585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-17
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty