Basic Information
| Provider Information | |||||||||
| NPI: | 1043501091 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592764429 | ||||||||
| FaxNumber: | 8592765939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 W 5TH ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407411688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063302377 | ||||||||
| FaxNumber: | 6063302369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2011 | ||||||||
| LastUpdateDate: | 04/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CARMEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6063306015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 700216 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.