Provider Demographics
NPI:1255357810
Name:FAIN, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FAIN
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 1:3205 SUMMIT SQUARE PL STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2650
Mailing Address - Country:US
Mailing Address - Phone:859-335-9041
Mailing Address - Fax:859-335-9072
Practice Address - Street 1:3205 SUMMIT SQUARE PL STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2650
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38615207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004577Medicaid
KYP00212459OtherRR MEDICARE
KY000000330279OtherANTHEM
OH2378958Medicaid
KY50005451OtherPASSPORT
KY64079957Medicaid
WV1069243OtherBWC
WV1069243OtherBWC
KY0693536Medicare ID - Type Unspecified
KYH77739Medicare UPIN