Basic Information
| Provider Information | |||||||||
| NPI: | 1962550020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN'S PRIMARY CARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471306016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122882488 | ||||||||
| FaxNumber: | 8122886603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1804 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471306016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122882488 | ||||||||
| FaxNumber: | 8122886603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 10/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8122882488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001741A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 23424 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | 3003535 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 01036153A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200043610A | 05 | IN | MEDICAID | 50015623 | 01 | KY | PASSPORT | OTHER | 7100141580 | 05 | KY | MEDICAID |