1750582961 NPI number — J. KELLY PATTERSON, M.D., P.S.C.

Table of content: (NPI 1750582961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750582961 NPI number — J. KELLY PATTERSON, M.D., P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J. KELLY PATTERSON, M.D., P.S.C.
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:
1750582961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 S MAIN
Provider Second Line Business Mailing Address:
PO 385
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-813-2520
Provider Business Mailing Address Fax Number:
270-713-0234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 SOUTH MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-813-2520
Provider Business Practice Location Address Fax Number:
270-713-0234
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
JACK
Authorized Official Middle Name:
KELLY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-586-5888

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  27213 , 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: 64272131 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65929200 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110158592 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000049404 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000305382 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 18D0712268 . This is a "CLIA NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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