Provider Demographics
NPI:1720397409
Name:KINGS DAUGHTERS MEDICAL SPECIALTIES INC
Entity Type:Organization
Organization Name:KINGS DAUGHTERS MEDICAL SPECIALTIES INC
Other - Org Name:KINGS DAUGHTERS MEDICAL SPECIALTIES - PLASTIC & RECONSTRUCTIVE SURGEON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITLATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-408-4401
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-2600
Mailing Address - Fax:606-408-2606
Practice Address - Street 1:617 23RD ST STE 105
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2890
Practice Address - Country:US
Practice Address - Phone:606-408-7500
Practice Address - Fax:606-408-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100140330Medicaid
KY01251Medicare PIN