Provider Demographics
NPI:1497970743
Name:CENTRAL KENTUCKY SURGICAL INSTITUTE, PSC
Entity type:Organization
Organization Name:CENTRAL KENTUCKY SURGICAL INSTITUTE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:270-465-7505
Mailing Address - Street 1:PO BOX 1114
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42719-1114
Mailing Address - Country:US
Mailing Address - Phone:270-465-7505
Mailing Address - Fax:270-789-3860
Practice Address - Street 1:1878 OLD LEBANON RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9663
Practice Address - Country:US
Practice Address - Phone:270-465-7505
Practice Address - Fax:270-789-3860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24667208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64246671Medicaid
KY000000062911OtherANTHEM BCBS
KYC78444Medicare UPIN
KY64246671Medicaid