1770773525 NPI number — ARCHER CLINIC ASSOCIATES

Table of content: (NPI 1770773525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770773525 NPI number — ARCHER CLINIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARCHER CLINIC ASSOCIATES
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:
1770773525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 UNIVERSITY DRIVE
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
PRESTONBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-886-3888
Provider Business Mailing Address Fax Number:
606-886-3818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PRESTONBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-3887
Provider Business Practice Location Address Fax Number:
606-886-3818
Provider Enumeration Date:
07/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HIERONYMUS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
606-886-3887

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , 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: 1002252 . This is a "UNITED MINE WORKERS OF AM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000046040 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 16846 . This is a "KY LICENSE NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 103141 . This is a "BLACK LUNG" identifier . This identifiers is of the category "OTHER".




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