Provider Demographics
NPI:1750382677
Name:COLORECTAL SURGICAL & GASTROENTEROLOGY ASSOCIATES PSC
Entity type:Organization
Organization Name:COLORECTAL SURGICAL & GASTROENTEROLOGY ASSOCIATES PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-278-6031
Mailing Address - Street 1:2620 WILHITE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3385
Mailing Address - Country:US
Mailing Address - Phone:859-278-6031
Mailing Address - Fax:859-277-7015
Practice Address - Street 1:2620 WILHITE DRIVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3385
Practice Address - Country:US
Practice Address - Phone:859-278-6031
Practice Address - Fax:859-277-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY05914096Medicaid
2056Medicare ID - Type Unspecified