Provider Demographics
NPI:1558761734
Name:ASHLAND INTEGRATED MEDICINE PSC
Entity Type:Organization
Organization Name:ASHLAND INTEGRATED MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VANHOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-393-0110
Mailing Address - Street 1:155 W. CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7364
Mailing Address - Country:US
Mailing Address - Phone:606-393-0110
Mailing Address - Fax:606-326-0114
Practice Address - Street 1:155 W. CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7364
Practice Address - Country:US
Practice Address - Phone:606-393-0110
Practice Address - Fax:606-326-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5449111N00000X
KY36483208600000X
332B00000X
KY3006910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100350560Medicaid
KY7100428120Medicaid
KY7100363920Medicaid
KYK123820Medicare PIN