Provider Demographics
NPI:1295746360
Name:EAST KENTUCKY EYE EAR NOSE AND THORAT SPECIALISTS LLC
Entity type:Organization
Organization Name:EAST KENTUCKY EYE EAR NOSE AND THORAT SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAZELETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-432-4494
Mailing Address - Street 1:255 CHURCH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3476
Mailing Address - Country:US
Mailing Address - Phone:606-432-4494
Mailing Address - Fax:606-432-0430
Practice Address - Street 1:255 CHURCH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3476
Practice Address - Country:US
Practice Address - Phone:606-432-4494
Practice Address - Fax:606-432-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22584207W00000X
KYPA295363A00000X
KY02303207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65935405Medicaid
KY65935405Medicaid
KY6879Medicare ID - Type Unspecified