Basic Information
| Provider Information | |||||||||
| NPI: | 1487755740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | C. MICHAEL LITTLEJOHN, MD, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 S JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424452379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703653343 | ||||||||
| FaxNumber: | 2703654467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424452379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703653343 | ||||||||
| FaxNumber: | 2703654467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 11/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | LITTLEJOHN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2703653343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30506 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64305063 | 05 | KY | MEDICAID |