Provider Demographics
NPI:1174235584
Name:FDC GEORGETOWN PLLC
Entity type:Organization
Organization Name:FDC GEORGETOWN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:022-952-0745
Mailing Address - Street 1:1006 LEAWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3523
Mailing Address - Country:US
Mailing Address - Phone:502-295-2074
Mailing Address - Fax:502-875-5567
Practice Address - Street 1:723 BUTTERMILK PIKE
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1304
Practice Address - Country:US
Practice Address - Phone:859-431-3900
Practice Address - Fax:859-431-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7615OtherLICENCE NUMBER