Provider Demographics
NPI:1528260734
Name:KENTUCKY SURGICAL ARTS PSC
Entity type:Organization
Organization Name:KENTUCKY SURGICAL ARTS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:IKRAMUDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-0682
Mailing Address - Street 1:5251 KY ROUTE 321
Mailing Address - Street 2:KENTUCKY SURGICAL ARTS PSC
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-9114
Mailing Address - Country:US
Mailing Address - Phone:606-886-0682
Mailing Address - Fax:606-886-0682
Practice Address - Street 1:5251 KY ROUTE 321
Practice Address - Street 2:KENTUCKY SURGICAL ARTS PSC
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9114
Practice Address - Country:US
Practice Address - Phone:606-886-0682
Practice Address - Fax:606-886-0682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19259208600000X
KY19463207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64194632Medicaid
KY64192594Medicaid
KY0752Medicare ID - Type UnspecifiedGROUP #
KY64192594Medicaid
KY64194632Medicaid