Provider Demographics
NPI:1003079781
Name:GLENN R WOMACK MD PSC
Entity Type:Organization
Organization Name:GLENN R WOMACK MD PSC
Other - Org Name:BUFFALO TRACE FAMILY HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-849-2323
Mailing Address - Street 1:732 ELIZAVILLE RD
Mailing Address - Street 2:PO BOX 344
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041
Mailing Address - Country:US
Mailing Address - Phone:606-849-2323
Mailing Address - Fax:606-849-2025
Practice Address - Street 1:732 ELIZAVILLE RD
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041
Practice Address - Country:US
Practice Address - Phone:606-849-2323
Practice Address - Fax:606-849-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty