Provider Demographics
NPI:1518113794
Name:KENTUCKY SURGICAL & WOUND SERVICES PSC
Entity Type:Organization
Organization Name:KENTUCKY SURGICAL & WOUND SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-704-3599
Mailing Address - Street 1:2934 DOLPHIN DR UNIT 757
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-4030
Mailing Address - Country:US
Mailing Address - Phone:270-704-3599
Mailing Address - Fax:270-713-0261
Practice Address - Street 1:105 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1269
Practice Address - Country:US
Practice Address - Phone:270-704-3599
Practice Address - Fax:270-713-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38878208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0627209Medicare PIN
KY00731Medicare PIN
KY0627407Medicare PIN
KY0627308Medicare PIN