Provider Demographics
NPI:1376692657
Name:KENTUCKY PAIN MANAGEMENT SERVICES
Entity Type:Organization
Organization Name:KENTUCKY PAIN MANAGEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-487-0776
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702
Mailing Address - Country:US
Mailing Address - Phone:606-487-0776
Mailing Address - Fax:606-487-0777
Practice Address - Street 1:311 ROY CAMPBELL DRIVE
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-487-0776
Practice Address - Fax:606-487-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208VP0000X, 363L00000X
KY29445261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000509781OtherANTHEM BCBS
KY7100002910Medicaid
KY29445OtherSTATE LICENSE #
KY00216Medicare PIN