Basic Information
| Provider Information | |||||||||
| NPI: | 1851474159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KENTUCKY ANESTHESIA P.S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 LEWIS HARGETT CIR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405033590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 NICHOLASVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592606100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 05/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | BROSTER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8592681030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1329545 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100191870 | 05 | KY | MEDICAID | 1329545 | 01 | KY | UMWA | OTHER |