Provider Demographics
NPI:1124091897
Name:PADUCAH OPHTHALMOLOGY ASC LLC
Entity type:Organization
Organization Name:PADUCAH OPHTHALMOLOGY ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6103
Mailing Address - Country:US
Mailing Address - Phone:270-442-1024
Mailing Address - Fax:270-442-1001
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7909
Practice Address - Country:US
Practice Address - Phone:270-442-1024
Practice Address - Fax:270-442-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300083261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36001212Medicaid
KY000000231770OtherANTHEM BLUE CROSS BLUE SH
IL=========001Medicaid
KY=========OtherTRICARE
KY36001212Medicaid
KYASC1018Medicare PIN