Basic Information
| Provider Information | |||||||||
| NPI: | 1194711150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICK | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 S LOOP RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593441600 | ||||||||
| FaxNumber: | 8593440091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 29604 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 174400000X | 29604 | KY | N | Other Service Providers | Specialist | 208600000X | 29604 | KY | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100056850 | 05 | KY | MEDICAID | 100354170 | 05 | IN | MEDICAID | P01058472 | 01 | KY | RAILROAD MEDICARE | OTHER | 0915148 | 05 | OH | MEDICAID | P00252704 | 01 | RAILROAD MEDICARE | OTHER | 64933096 | 05 | KY | MEDICAID |