Provider Demographics
NPI:1073503611
Name:PRIMARY CARE ASSOCIATES OF SOUTHERN KENTUCKY, PLLC
Entity Type:Organization
Organization Name:PRIMARY CARE ASSOCIATES OF SOUTHERN KENTUCKY, PLLC
Other - Org Name:GLASGOW PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-651-6791
Mailing Address - Street 1:1330 N RACE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3465
Mailing Address - Country:US
Mailing Address - Phone:270-651-6791
Mailing Address - Fax:270-651-3182
Practice Address - Street 1:1330 N RACE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3465
Practice Address - Country:US
Practice Address - Phone:270-651-6791
Practice Address - Fax:270-651-3182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65929614Medicaid
KY65929614Medicaid