Basic Information
| Provider Information | |||||||||
| NPI: | 1427082338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY FAMILY CLINIC PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 784 HWY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067689190 | ||||||||
| FaxNumber: | 6067689180 | ||||||||
| Practice Location | |||||||||
| Address1: | 784 HWY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067689190 | ||||||||
| FaxNumber: | 6067689180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KASSIS | ||||||||
| AuthorizedOfficialFirstName: | TAUFIK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6067689190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36974 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QP2300X | 700182 | KY | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 363L00000X | 36974 | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QR1300X | 900200 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 183949 | 01 | KY | RURAL HEALTH MEDICARE | OTHER | BK7849663 | 01 | DEA | OTHER | 35002021 | 05 | KY | MEDICAID | 65945198 | 05 | KY | MEDICAID | 64055361 | 05 | KY | MEDICAID | 7100010420 | 05 | KY | MEDICAID | 11493417 | 01 | KY | CAQH | OTHER | 7100000960 | 05 | KY | MEDICAID | 7100010230 | 05 | KY | MEDICAID |