Provider Demographics
NPI:1922269224
Name:MAYSVILLE DIAGNOSTIC CENTER SLEEP LAB
Entity Type:Organization
Organization Name:MAYSVILLE DIAGNOSTIC CENTER SLEEP LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-759-9353
Mailing Address - Street 1:910 KENTON STATION DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9658
Mailing Address - Country:US
Mailing Address - Phone:606-759-0073
Mailing Address - Fax:606-759-0075
Practice Address - Street 1:901 KENTON STATION DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9609
Practice Address - Country:US
Practice Address - Phone:606-759-0073
Practice Address - Fax:606-759-0075
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAYSVILLE DIAGNOSTIC CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-19
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730122261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000555662OtherANTHEM
KY9380101Medicare PIN