Basic Information
| Provider Information | |||||||||
| NPI: | 1699850263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON PURCHASE MEDICAL ASSOCIATES, PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 MEDICAL CENTER DR STE 206 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414522 | ||||||||
| FaxNumber: | 2704414822 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414200 | ||||||||
| FaxNumber: | 2704414398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | CARMEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2705385866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 173000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65923831 | 05 | KY | MEDICAID |