Basic Information
| Provider Information | |||||||||
| NPI: | 1235165606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS AFFILIATED CARE P.S.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GASTROINTESTINAL ENDOSCOPY CENTER OF OWENSBORO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1919 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423021919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262273 | ||||||||
| FaxNumber: | 2709265200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E PARRISH AVE | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423031449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709262273 | ||||||||
| FaxNumber: | 2709265200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 12/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOARMAN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2709262273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000000333384 | 01 | KY | ANTHEM BC/BS | OTHER | 200491020A | 05 | IN | MEDICAID | 36001345 | 05 | KY | MEDICAID |