Basic Information
| Provider Information | |||||||||
| NPI: | 1609811413 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACS PRIMARY CARE PHYSICIANS-MIDWEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 633815 | ||||||||
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| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452633815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882031274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 N EAGLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599675000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 05/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | DABBS | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8656931000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2441613 | 01 | KY | PASSPORT ADVANTAGE CARE | OTHER | 000000197128 | 01 | KY | ANTHEM BCBS OF KENTUCKY | OTHER | 65938102 | 05 | KY | MEDICAID | 1172638 | 01 | KY | PASSPORT MEDICAID HEALTH PLAN | OTHER |