Provider Demographics
NPI:1043501091
Name:MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MARYMOUNT MEDICAL CENTER PHYSICIAN SERVICES
Other - Org Name:PREMIER FAMILY HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:COO/VP FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:CARMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-330-6015
Mailing Address - Street 1:740 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8601
Mailing Address - Country:US
Mailing Address - Phone:859-276-4429
Mailing Address - Fax:859-276-5939
Practice Address - Street 1:1406 W 5TH ST
Practice Address - Street 2:STE 201
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1688
Practice Address - Country:US
Practice Address - Phone:606-330-2377
Practice Address - Fax:606-330-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700216261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care