Provider Demographics
NPI:1982879888
Name:EASTERN KY CENTER FOR PLASTIC, RECONSTRUCTIVE & COSMETIC SURGERY
Entity Type:Organization
Organization Name:EASTERN KY CENTER FOR PLASTIC, RECONSTRUCTIVE & COSMETIC SURGERY
Other - Org Name:KENTUCKY CENTER FOR PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYN T
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-432-0061
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2257
Mailing Address - Country:US
Mailing Address - Phone:606-432-0061
Mailing Address - Fax:606-432-0095
Practice Address - Street 1:126 TRIVETTE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1275
Practice Address - Country:US
Practice Address - Phone:606-432-0061
Practice Address - Fax:606-432-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64256423Medicaid
KY0114191000OtherWV MEDICAID
KY1532903OtherUMWA
KY000000051790OtherBC/BS
KY240005992OtherR/R MEDICARE
KY0114191000OtherWV MEDICAID
KYC76650Medicare UPIN