Provider Demographics
NPI:1770779084
Name:S DOUGLAS DEITCH MD PSC
Entity type:Organization
Organization Name:S DOUGLAS DEITCH MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:DEITCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-325-3299
Mailing Address - Street 1:2301 LEXINGTON AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2873
Mailing Address - Country:US
Mailing Address - Phone:606-325-3299
Mailing Address - Fax:606-325-1386
Practice Address - Street 1:2301 LEXINGTON AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2873
Practice Address - Country:US
Practice Address - Phone:606-325-3299
Practice Address - Fax:606-325-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26535174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4347345OtherAETNA
KY64265358Medicaid
KY1389552OtherUMWA
WV0042484000Medicaid
KY1498201OtherMEDICARE ID
KY4982OtherMEDICARE ID GROUP
KY000000049311OtherBLUE CROSS
KY1030745OtherWEST VIRGINIA WORKERS COM
OH0742594Medicaid
KY64265358Medicaid
KY1389552OtherUMWA