Provider Demographics
NPI:1164406237
Name:PROFESSIONAL MEDICAL HEALTH CARE CLINIC
Entity Type:Organization
Organization Name:PROFESSIONAL MEDICAL HEALTH CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-218-3500
Mailing Address - Street 1:1500 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224
Mailing Address - Country:US
Mailing Address - Phone:606-218-3500
Mailing Address - Fax:606-218-4560
Practice Address - Street 1:1500 MAIN STREET
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224
Practice Address - Country:US
Practice Address - Phone:606-218-3500
Practice Address - Fax:606-218-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY730055261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9374601Medicare PIN
KYP00146457Medicare PIN