Provider Demographics
NPI:1619908613
Name:KENTUCKIANA COLON AND RECTAL SURGERY, PLLC
Entity Type:Organization
Organization Name:KENTUCKIANA COLON AND RECTAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-583-8005
Mailing Address - Street 1:4121 DUTCHMANS LN
Mailing Address - Street 2:SUITE 515
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4737
Mailing Address - Country:US
Mailing Address - Phone:502-583-8005
Mailing Address - Fax:
Practice Address - Street 1:4121 DUTCHMANS LN
Practice Address - Street 2:SUITE 515
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4737
Practice Address - Country:US
Practice Address - Phone:502-583-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30849208C00000X
363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934739Medicaid
KY7100015770Medicaid
IN200323220AMedicaid
KYCK6017OtherRAILROAD MEDICARE
IN200323220AMedicaid