Provider Demographics
| NPI: | 1982657524 |
|---|---|
| Name: | KENTUCKY PAIN PHYSICIANS, PSC |
| Entity Type: | Organization |
| Organization Name: | KENTUCKY PAIN PHYSICIANS, PSC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CMO |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | GAY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | RICHARDSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 770-850-8464 |
| Mailing Address - Street 1: | 286 US HIGHWAY 23 N |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PRESTONSBURG |
| Mailing Address - State: | KY |
| Mailing Address - Zip Code: | 41653-8732 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 606-874-0032 |
| Mailing Address - Fax: | 606-874-0064 |
| Practice Address - Street 1: | 286 US HIGHWAY 23 N |
| Practice Address - Street 2: | |
| Practice Address - City: | PRESTONSBURG |
| Practice Address - State: | KY |
| Practice Address - Zip Code: | 41653-8732 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 606-874-0032 |
| Practice Address - Fax: | 606-874-0064 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-17 |
| Last Update Date: | 2016-07-11 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 2081P2900X, 291U00000X, 332B00000X, 363A00000X, 363AM0700X, 363AS0400X, 363L00000X, 363LA2200X, 363LX0106X | ||
| KY | 2081P2900X, 208VP0000X, 208VP0014X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
| No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
| No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |
| No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LX0106X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| KY | 7100240830 | Medicaid | |
| KY | 7100265660 | Medicaid | |
| KY | 64126766 | Medicaid | |
| KY | 7100033310 | Medicaid | |
| KY | 7100240700 | Medicaid | |
| KY | 7100239010 | Medicaid | |
| KY | 7100242090 | Medicaid | |
| KY | C23662 | Medicare UPIN | |
| KY | 7100033310 | Medicaid | |
| KY | 6371090001 | Medicare NSC |
