Provider Demographics
NPI:1225136153
Name:LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS PSC
Entity Type:Organization
Organization Name:LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:MCKEMIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:859-234-9611
Mailing Address - Street 1:1210 KY HIGHWAY 36 E
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-7490
Mailing Address - Country:US
Mailing Address - Phone:859-234-9611
Mailing Address - Fax:859-235-0878
Practice Address - Street 1:1210 KY HIGHWAY 36 E
Practice Address - Street 2:SUITE 2A
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-7490
Practice Address - Country:US
Practice Address - Phone:859-234-9611
Practice Address - Fax:859-235-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934341Medicaid
KY6734Medicare PIN
KY65934341Medicaid