Provider Demographics
NPI:1528120862
Name:KENTUCKY DIABETES ENDOCRINOLOGY CENTER, PSC
Entity type:Organization
Organization Name:KENTUCKY DIABETES ENDOCRINOLOGY CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-227-8015
Mailing Address - Street 1:417 E CAMBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8132
Mailing Address - Country:US
Mailing Address - Phone:859-351-3801
Mailing Address - Fax:
Practice Address - Street 1:417 E CAMBRIDGE LN
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8132
Practice Address - Country:US
Practice Address - Phone:859-351-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY659 282 36Medicaid
1408233OtherUMWA
K008543OtherCHAMPUS
208448OtherBLACK LUNG
KY3854Medicare ID - Type UnspecifiedGROUP #