Provider Demographics
NPI:1003004912
Name:ST. JOHN NEUMANN'S EXTENDED HOURS CLINIC
Entity Type:Organization
Organization Name:ST. JOHN NEUMANN'S EXTENDED HOURS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-666-4011
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0606
Mailing Address - Country:US
Mailing Address - Phone:606-666-4011
Mailing Address - Fax:606-666-5801
Practice Address - Street 1:1389 HIGHWAY 15 NORTH
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-4011
Practice Address - Fax:606-666-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY24420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty