Basic Information
| Provider Information | |||||||||
| NPI: | 1568910933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRVIEW PHYSICIANS NETWORK, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JENNIE STUART MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422401961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707072100 | ||||||||
| FaxNumber: | 2707072103 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | HOPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422401963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708864625 | ||||||||
| FaxNumber: | 2708866619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2708870100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JENNIE STUART MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.