Provider Demographics
NPI:1407924806
Name:MACLIMORE CLINIC
Entity Type:Organization
Organization Name:MACLIMORE CLINIC
Other - Org Name:SPRINGS URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:KEOWN
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)
Authorized Official - Phone:270-852-1632
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG C STE 104
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-852-1632
Mailing Address - Fax:270-852-1633
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG C STE 104
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-852-1632
Practice Address - Fax:270-852-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17376207Q00000X
KYPA 340363A00000X
KYPA 334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C64949OtherUPIN
KY331024OtherANTHEM
KY6417376880Medicaid
363734OtherANTHEM
KY95003349Medicaid
KY0268506Medicare PIN
363734OtherANTHEM
KY331024OtherANTHEM
KY909704Medicare PIN
0909705Medicare PIN