Basic Information
| Provider Information | |||||||||
| NPI: | 1457488744 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIKEVILLE MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2917 | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415022917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | 6062184562 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 BYPASS RD | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415011689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | 6062184562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAGY | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6062183500 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PIKEVILLE MEDICAL CENTER INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | 730093 | KY | N | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7100032480 | 05 | KY | MEDICAID | 65928129 | 05 | KY | MEDICAID | 000000056961 | 01 | KY | BCBS PHYSICIAN GROUP | OTHER |