Provider Demographics
NPI:1043812696
Name:GERIATRIC ESSENTIALS, PC
Entity Type:Organization
Organization Name:GERIATRIC ESSENTIALS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-410-7719
Mailing Address - Street 1:PO BOX 12432
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0141
Mailing Address - Country:US
Mailing Address - Phone:731-410-7719
Mailing Address - Fax:731-214-1816
Practice Address - Street 1:402 W FARTHING ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2900
Practice Address - Country:US
Practice Address - Phone:731-571-8808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GERIATRIC ESSENTIALS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100689200Medicaid