Basic Information
| Provider Information | |||||||||
| NPI: | 1295716694 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY CARE MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420719303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707599200 | ||||||||
| FaxNumber: | 2707599966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420719303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707599200 | ||||||||
| FaxNumber: | 2707599966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2707599200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | R0855 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | C10499 | 01 | KY | RAILROAD MEDICARE GRP NUM | OTHER | 65922809 | 05 | KY | MEDICAID | 000000060296 | 01 | KY | ANTHEM GROUP PROV NUMBER | OTHER |