Provider Demographics
NPI:1922038611
Name:ESTRIDGE, MITCHAEL GENE (MD)
Entity Type:Individual
Prefix:
First Name:MITCHAEL
Middle Name:GENE
Last Name:ESTRIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:SUITE A-510
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-258-6784
Mailing Address - Fax:859-258-6796
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE A-510
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-258-6784
Practice Address - Fax:859-258-6796
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24442207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KY64000912Medicaid
KYCB5773OtherRAILROAD MEDICARE GROUP
KY110055339OtherRAILROAD MEDICARE PIN
D95909Medicare UPIN
KY0091012Medicare ID - Type Unspecified
KYCB5773OtherRAILROAD MEDICARE GROUP