Provider Demographics
NPI:1376689620
Name:WILLIAMSBURG FAMILY MEDICINE CENTER
Entity Type:Organization
Organization Name:WILLIAMSBURG FAMILY MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPC
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-0269
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0247
Mailing Address - Country:US
Mailing Address - Phone:423-784-0269
Mailing Address - Fax:
Practice Address - Street 1:475 N HIGHWAY 25 W STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1576
Practice Address - Country:US
Practice Address - Phone:606-549-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900065261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35000553Medicaid
KY183832Medicare ID - Type Unspecified