Provider Demographics
NPI:1295097319
Name:KENTUCKY BREAST CARE
Entity type:Organization
Organization Name:KENTUCKY BREAST CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODROOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-658-9535
Mailing Address - Street 1:38 JOE T PETTEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-8553
Mailing Address - Country:US
Mailing Address - Phone:606-658-9535
Mailing Address - Fax:270-866-9716
Practice Address - Street 1:38 JOE T PETTY DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-8553
Practice Address - Country:US
Practice Address - Phone:606-658-9535
Practice Address - Fax:270-866-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100212880Medicaid