Basic Information
| Provider Information | |||||||||
| NPI: | 1174571756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIKEVILLE MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROFESSIONAL MEDICAL HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 BYPASS RD | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415011689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | 6062184560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | INEZ | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | 6062184560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | DANNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6062183500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3402X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
ID Information
| ID | Type | State | Issuer | Description | 730055 | 01 | KY | STATE LICENSE # | OTHER | 01012251 | 05 | KY | MEDICAID |