Provider Demographics
NPI:1336204676
Name:MARK A. DELOMAS, M.D., P.S.C.
Entity type:Organization
Organization Name:MARK A. DELOMAS, M.D., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-268-1030
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:141 N EAGLE CREEK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1832
Practice Address - Country:US
Practice Address - Phone:859-543-1000
Practice Address - Fax:859-543-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA736363A00000X
207L00000X
KY3002751363L00000X
KY9813207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9813Medicare PIN