Provider Demographics
NPI:1801951462
Name:ANDOVER FAMILY MEDICINE
Entity type:Organization
Organization Name:ANDOVER FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-268-0254
Mailing Address - Street 1:PO BOX 55168
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40555-5168
Mailing Address - Country:US
Mailing Address - Phone:859-268-0254
Mailing Address - Fax:859-263-0159
Practice Address - Street 1:2801 PALUMBO DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1317
Practice Address - Country:US
Practice Address - Phone:859-268-0254
Practice Address - Fax:859-263-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1224232OtherCHA
KY000000371547OtherANTHEM BCBS
KY2075768OtherFIRST HEALTH
KY2075768OtherCCN
KY5276688OtherAETNA
KY65944324Medicaid
KY84146OtherWASAU
KY2075768OtherFIRST HEALTH
KY84146OtherWASAU