Provider Demographics
NPI:1326529827
Name:DANVILLE MEDICAL SPECIALTY
Entity Type:Organization
Organization Name:DANVILLE MEDICAL SPECIALTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOCH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:859-319-8487
Mailing Address - Street 1:PO BOX 23794
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4488
Mailing Address - Country:US
Mailing Address - Phone:859-319-8487
Mailing Address - Fax:
Practice Address - Street 1:504 TENIKAT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1751
Practice Address - Country:US
Practice Address - Phone:859-319-8487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty