Provider Demographics
NPI:1568528164
Name:LAWRENCEBURG CLINIC MEDICINE
Entity Type:Organization
Organization Name:LAWRENCEBURG CLINIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-839-5592
Mailing Address - Street 1:504 W BROADWAY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-1541
Mailing Address - Country:US
Mailing Address - Phone:502-839-5592
Mailing Address - Fax:502-839-1041
Practice Address - Street 1:504 W BROADWAY ST
Practice Address - Street 2:SUITE B
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-1541
Practice Address - Country:US
Practice Address - Phone:502-839-5592
Practice Address - Fax:502-839-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1174516306OtherINDIVIDUAL NPI NUMBER
KY4500041100OtherEPSDT
KY65916165Medicaid
KYC63147Medicare UPIN
KY4500041100OtherEPSDT
KY65916165Medicaid