Basic Information
| Provider Information | |||||||||
| NPI: | 1710219019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN KENTUCKY MEDICINE ASSOCIATES, LLC | ||||||||
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| OtherOrganizationName: | PRIME CARE MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 990 WILKINSON TRCE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421033404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707814043 | ||||||||
| FaxNumber: | 2707814196 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 WILKINSON TRCE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421033404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707814043 | ||||||||
| FaxNumber: | 2707814196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6153767600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LA2200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.