Basic Information
| Provider Information | |||||||||
| NPI: | 1366960908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | PMC URGENT CARE AND OCCUPATIONAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4023 REAS LANE | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471502228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125906936 | ||||||||
| FaxNumber: | 8129134338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022220028 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2017 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | HENRY | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8125906936 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.