Active NPI
Kenneth R Luckay, DO
- Family Medicine Physician
- Roanoke, VA
National Provider Identifier
1770572331
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 0102049893
- Practice address
- 4515 Brambleton Ave
Suite B
Roanoke, VA 24018-3436 - Phone
- (540) 777-6807
- Fax
- (855) 248-9858
- NPI assigned
- Oct 17, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 0102049893 | VA | Primary |
Addresses
Primary practice location
4515 Brambleton Ave
Suite B
Roanoke, VA 24018-3436
Mailing address
4515 Brambleton Ave
Suite B
Roanoke, VA 24018-3436
Phone (540) 777-6807
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 005615127 | Medicaid | VA | |
| 362206700 | Other | VA | DEPT OF LABOR |
| 441414 | Other | VA | ANTHEM |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Oct 1, 2016 through Oct 1, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0102049893 | VA | MD | Family Medicine Physician |
Interoperability endpoints
- kenneth.luckay.1@8253.direct.athenahealth.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1129507200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1397174400000",
"number": "1770572331",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4515 BRAMBLETON AVE",
"address_2": "SUITE B",
"city": "ROANOKE",
"state": "VA",
"postal_code": "240183436",
"telephone_number": "540-777-6807",
"fax_number": "855-248-9858"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4515 BRAMBLETON AVE",
"address_2": "SUITE B",
"city": "ROANOKE",
"state": "VA",
"postal_code": "240183436",
"telephone_number": "540-777-6807",
"fax_number": "855-248-9858"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LUCKAY",
"first_name": "KENNETH",
"middle_name": "R",
"credential": "DO",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-10-17",
"last_updated": "2014-04-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "VA",
"license": "0102049893",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "005615127",
"state": "VA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DEPT OF LABOR",
"identifier": "362206700",
"state": "VA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM",
"identifier": "441414",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Roanoke, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.