1700827599 NPI number — FAMILY MEDICAL CARE OF MANCHESTER

Table of content: (NPI 1700827599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700827599 NPI number — FAMILY MEDICAL CARE OF MANCHESTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CARE OF MANCHESTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700827599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94 MARIE LANGDON DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40962-6353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-599-9955
Provider Business Mailing Address Fax Number:
606-599-9966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94 MARIE LANGDON DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40962-6353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-599-9955
Provider Business Practice Location Address Fax Number:
606-599-9966
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IRWIN
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
GERARDY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-599-9955

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  38637 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C92418 . This is a "CUMBERLAND HEALTHCARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 31000813 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020252900 . This is a "BLACK LUNG GROUP #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1168920 . This is a "PASSPORT GROUP PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000195439 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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