Basic Information
| Provider Information | |||||||||
| NPI: | 1750610663 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEADOWVIEW PHYSICIAN PRACTICE LLC | ||||||||
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| OtherOrganizationName: | MEADOWVIEW ORTHOPEDIC CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 KENTON STATION DR | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067595337 | ||||||||
| FaxNumber: | 6067595340 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 KENTON STATION DR | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067595337 | ||||||||
| FaxNumber: | 6067595340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2009 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6155651556 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100142790 | 05 | KY | MEDICAID |