Basic Information
| Provider Information | |||||||||
| NPI: | 1518915891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PYMA MEDICAL, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIANS EXPRESS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068781181 | ||||||||
| FaxNumber: | 6068781267 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 LONDON MOUNTAIN VIEW DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407416601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068781181 | ||||||||
| FaxNumber: | 6068781267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERKINS | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6068781181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PYMA MEDICAL,PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
| ID | Type | State | Issuer | Description | 78905239 | 05 | KY | MEDICAID | 65944910 | 05 | KY | MEDICAID |