Basic Information
| Provider Information | |||||||||
| NPI: | 1548316763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VERSAILLES FAMILY MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598790111 | ||||||||
| FaxNumber: | 8598790363 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598790111 | ||||||||
| FaxNumber: | 8598790363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2007 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8598790111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family 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 | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 40454 | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.