Provider Demographics
NPI:1831386192
Name:EASTERN KENTUCKY UNIVERSITY
Entity type:Organization
Organization Name:EASTERN KENTUCKY UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-259-0717
Mailing Address - Street 1:1306 VERSAILLES RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1795
Mailing Address - Country:US
Mailing Address - Phone:859-259-0717
Mailing Address - Fax:859-254-7874
Practice Address - Street 1:151 N EAGLE CREEK
Practice Address - Street 2:SUITE 220
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1892
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:859-254-7874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN KENTUCKY UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-01
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31001118Medicaid
KY31001118Medicaid