Provider Demographics
NPI:1992735559
Name:CHILDERS, KYLE JAMISON (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMISON
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 LAKECREST CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1707
Mailing Address - Country:US
Mailing Address - Phone:859-258-8660
Mailing Address - Fax:859-258-8610
Practice Address - Street 1:3085 LAKECREST CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1707
Practice Address - Country:US
Practice Address - Phone:859-258-8660
Practice Address - Fax:859-258-8610
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37889208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACC4966OtherRR MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
KY64066343Medicaid
GAP00004985OtherRR MEDICARE PIN
KY0169Medicare PIN
0787001Medicare ID - Type Unspecified
KY4000501OtherMEDICARE LAB GROUP