Basic Information
| Provider Information | |||||||||
| NPI: | 1114060266 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDER MANAGEMENT & DEVELOPMENT CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PROVIDER CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404758488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596230898 | ||||||||
| FaxNumber: | 8596230843 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PROVIDER CT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404758488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596230898 | ||||||||
| FaxNumber: | 8596230843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DURANT | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASST. VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8596230898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 90160763 | 05 | KY | MEDICAID |