Provider Demographics
NPI:1770568578
Name:NORTHEASTERN KENTUCKY SURGEONS, PSC
Entity type:Organization
Organization Name:NORTHEASTERN KENTUCKY SURGEONS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-325-1151
Mailing Address - Street 1:617 23RD ST
Mailing Address - Street 2:SUITE 13
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2845
Mailing Address - Country:US
Mailing Address - Phone:606-325-1151
Mailing Address - Fax:606-324-4168
Practice Address - Street 1:617 23RD ST
Practice Address - Street 2:SUITE 13
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2845
Practice Address - Country:US
Practice Address - Phone:606-325-1151
Practice Address - Fax:606-324-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65936429Medicaid
KY31L2OtherBLUE SHIELD
6940Medicare ID - Type Unspecified