Basic Information
Provider Information | |||||||||
NPI: | 1710207865 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIKEVILLE MEDICAL CENTER INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PIKEVILLE MEDICAL CENTER CLINIC @ WALMART | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 432 | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415020432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062183500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 254 CASSIDY BLVD | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415011426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6064370123 | ||||||||
FaxNumber: | 6062184788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2010 | ||||||||
LastUpdateDate: | 10/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAGY | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6062183500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1300366 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363L00000X | 1300366 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X | 1300366 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 65922361 | 05 | KY |   | MEDICAID | 7100155700 | 05 | KY |   | MEDICAID | 7100155720 | 05 | KY |   | MEDICAID | 7100155970 | 05 | KY |   | MEDICAID | 7100155680 | 05 | KY |   | MEDICAID | 7100152490 | 05 | KY |   | MEDICAID |