Basic Information
| Provider Information | |||||||||
| NPI: | 1801106281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIKEVILLE MEDICAL CENTER INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIKEVILLE MEDICAL CENTER CLINIC AT WHITESBURG WALMART | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 BYPASS ROAD | ||||||||
| Address2: | |||||||||
| City: | PIKEVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415011689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 148 SUITE A | ||||||||
| Address2: | WHITESBURG PLAZA | ||||||||
| City: | WHITESBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062183500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | HAGY | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6062183500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 65922361 | 05 | KY | MEDICAID |