Provider Demographics
NPI:1710252622
Name:KENTUCKY MSO LLC
Entity Type:Organization
Organization Name:KENTUCKY MSO LLC
Other - Org Name:GEORGETOWN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:1138 LEXINGTON RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9672
Mailing Address - Country:US
Mailing Address - Phone:502-867-0420
Mailing Address - Fax:502-867-0222
Practice Address - Street 1:1138 LEXINGTON RD
Practice Address - Street 2:SUITE 130
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9672
Practice Address - Country:US
Practice Address - Phone:502-867-0420
Practice Address - Fax:502-867-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty