Basic Information
| Provider Information | |||||||||
| NPI: | 1942275805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMARY CARE CENTERS OF EASTERN KENTUCKY-HAZARD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1988 | ||||||||
| Address2: | |||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064357642 | ||||||||
| FaxNumber: | 6064365282 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 TOWN AND COUNTRY LN | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | HAZARD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 417019524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064391300 | ||||||||
| FaxNumber: | 6064391400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6064391300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 900161 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 7100167330 | 05 | KY | MEDICAID |