Basic Information
| Provider Information | |||||||||
| NPI: | 1285802645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | J S OSBORNE OD PSC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | J SHANE OSBORNE OD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3469 N MAYO TRL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415013265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Practice Location | |||||||||
| Address1: | 3469 N MAYO TRL | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415013265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064377702 | ||||||||
| FaxNumber: | 6064372307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSBORNE | ||||||||
| AuthorizedOfficialFirstName: | J. SHANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6064377702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1230-DT | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 77012300 | 05 | KY | MEDICAID |