Basic Information
| Provider Information | |||||||||
| NPI: | 1073503611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY CARE ASSOCIATES OF SOUTHERN KENTUCKY, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLASGOW PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 N RACE ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706516791 | ||||||||
| FaxNumber: | 2706513182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 N RACE ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421413465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706516791 | ||||||||
| FaxNumber: | 2706513182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | SIMMONS | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2706516791 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65929614 | 05 | KY | MEDICAID |