Provider Demographics
NPI:1053305524
Name:BARDSTOWN PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:BARDSTOWN PRIMARY CARE, PLLC
Other - Org Name:PHYSICIANS TO CHILDREN & ADOLESCENTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:NALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-348-7554
Mailing Address - Street 1:201 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1142
Mailing Address - Country:US
Mailing Address - Phone:502-350-0050
Mailing Address - Fax:502-348-6505
Practice Address - Street 1:201 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1142
Practice Address - Country:US
Practice Address - Phone:502-348-7554
Practice Address - Fax:502-337-6070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCH3784Medicare UPIN
KY5515Medicare PIN