Basic Information
| Provider Information | |||||||||
| NPI: | 1154591212 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADAIR COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WESTLAKE PRIMARY CARE NP GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 810 JAMESTOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427281010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703844753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 810 JAMESTOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427281010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703844764 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUNGATE | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2703844753 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTLAKE PRIMARY CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 78902186 | 05 | KY | MEDICAID |