Basic Information
| Provider Information | |||||||||
| NPI: | 1023091600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMECARE PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 WOODLAND DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2413 RING RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427015924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707654535 | ||||||||
| FaxNumber: | 2707631901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZOELLER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2707654535 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207QA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 26429 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1507510 | 05 | TN | MEDICAID | 78904083 | 05 | KY | MEDICAID | 7100060440 | 05 | KY | MEDICAID | 65922940 | 05 | KY | MEDICAID |