Provider Demographics
NPI:1528644309
Name:SANDBERG, MEGAN KILEY
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KILEY
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 HARRODSBURG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1712
Mailing Address - Country:US
Mailing Address - Phone:859-899-7993
Mailing Address - Fax:
Practice Address - Street 1:2040 HARRODSBURG RD STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1712
Practice Address - Country:US
Practice Address - Phone:859-899-7993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY59559207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program