Basic Information
| Provider Information | |||||||||
| NPI: | 1649359514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBBS | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400319122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025930083 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 NEW MOODY LN | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400319122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025930083 | ||||||||
| FaxNumber: | 5022220029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 05/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30727 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0100865 | 01 | UHC | OTHER | 64307275 | 05 | KY | MEDICAID | 000052153D | 01 | KY | HUMANA - NCMA | OTHER | 118157 | 01 | KY | SIHO - NICC | OTHER | 50027441 | 01 | KY | PASSPORT - NCMA | OTHER | 019456 | 01 | KY | SIHO - NCMA | OTHER | 6935264 | 01 | KY | CIGNA - NCMA | OTHER | 000000644690 | 01 | KY | ANTHEM - NCMA | OTHER | 000000675746 | 01 | KY | ANTHEM - NICC | OTHER |