Provider Demographics
NPI:1467456855
Name:MYERS, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 VILLAGE PLAZA, PMB 136
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1711
Mailing Address - Country:US
Mailing Address - Phone:502-633-0192
Mailing Address - Fax:502-633-4164
Practice Address - Street 1:1741 MIDLAND TRL
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1711
Practice Address - Country:US
Practice Address - Phone:502-633-0192
Practice Address - Fax:502-633-4164
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32619207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY122601OtherCHA
KY5134693001OtherCIGNA
KY5344332OtherAETNA
KY64326192Medicaid
KYPASSPORT ADVANTAGEOther2434349000
KY000000041773OtherANTHEM
KY000802487OtherHUMANA
KY1063266OtherPASSPORT HEALTH PLAN
KY122601OtherCHA
KY0524701Medicare PIN
KY1063266OtherPASSPORT HEALTH PLAN
KY0541301Medicare PIN