Basic Information
| Provider Information | |||||||||
| NPI: | 1144491671 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAINTSVILLE HMA PHYSICIAN MANGAMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WOMEN'S CENTER OF PAINTSVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 609 JAMES TRIMBLE BLVD | ||||||||
| Address2: | |||||||||
| City: | PAINTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412401055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067896844 | ||||||||
| FaxNumber: | 6067894157 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 JAMES TRIMBLE BLVD | ||||||||
| Address2: | |||||||||
| City: | PAINTSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 412401055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067896844 | ||||||||
| FaxNumber: | 6067894157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6067896844 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH MANAGEMENT ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 19716 | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 65946113 | 05 | KY | MEDICAID |