Provider Demographics
NPI:1114060266
Name:PROVIDER MANAGEMENT & DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:PROVIDER MANAGEMENT & DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. VP OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-623-0898
Mailing Address - Street 1:300 PROVIDER CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8488
Mailing Address - Country:US
Mailing Address - Phone:859-623-0898
Mailing Address - Fax:859-623-0843
Practice Address - Street 1:300 PROVIDER CT
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8488
Practice Address - Country:US
Practice Address - Phone:859-623-0898
Practice Address - Fax:859-623-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90160763Medicaid