Provider Demographics
NPI:1053382788
Name:MEDICAL INVESTMENT TRUST
Entity type:Organization
Organization Name:MEDICAL INVESTMENT TRUST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DJIEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-432-0174
Mailing Address - Street 1:PO BOX 2708
Mailing Address - Street 2:ASTHMA AND ALLERGY CENTER
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2708
Mailing Address - Country:US
Mailing Address - Phone:606-432-0174
Mailing Address - Fax:606-437-0438
Practice Address - Street 1:156 ISLAND CREEK RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9340
Practice Address - Country:US
Practice Address - Phone:606-432-0174
Practice Address - Fax:606-437-0438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17816207K00000X, 207K00000X
KY3001627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65-922866Medicaid
KY2891Medicare PIN