Basic Information
| Provider Information | |||||||||
| NPI: | 1669670816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAYNESBURG CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 435 | ||||||||
| Address2: | |||||||||
| City: | WAYNESBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404890435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063796646 | ||||||||
| FaxNumber: | 6063795707 | ||||||||
| Practice Location | |||||||||
| Address1: | 14098 US HIGHWAY 27 S | ||||||||
| Address2: | |||||||||
| City: | WAYNESBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404898253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063796646 | ||||||||
| FaxNumber: | 6063795707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | SIMS | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DUVALL | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6063651547 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261QR1300X | 900205 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 183954 | 01 | KY | MEDICARE PART A | OTHER | 7100019500 | 05 | KY | MEDICAID | 00361 | 01 | KY | MEDICARE PART B | OTHER |