Basic Information
| Provider Information | |||||||||
| NPI: | 1982876173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CASEY COUNTY PRIMARY CARE NURSING GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 187 WOLFORD AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067878348 | ||||||||
| FaxNumber: | 6067879717 | ||||||||
| Practice Location | |||||||||
| Address1: | 187 WOLFORD AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425393278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067878348 | ||||||||
| FaxNumber: | 6067879717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | TUNGATE | ||||||||
| AuthorizedOfficialFirstName: | REX | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2703844753 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASEY COUNTY HOSPITAL DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7890229300 | 05 | KY | MEDICAID |