Basic Information
| Provider Information | |||||||||
| NPI: | 1083843007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIKEVILLE MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2917 | ||||||||
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| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415022917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | 6062184562 | ||||||||
| Practice Location | |||||||||
| Address1: | 9428 HIGHWAY 805 | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415378182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068320023 | ||||||||
| FaxNumber: | 6068320024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2009 | ||||||||
| LastUpdateDate: | 07/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6062184502 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PIKEVILLE MEDICAL CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 65922361 | 05 | KY | MEDICAID |