MACLIMORE CLINIC LLC

Provider Demographics

• NPI: 1497707335
• Name: MACLIMORE CLINIC LLC
• Entity Type: Organization
• Organization Name: MACLIMORE CLINIC LLC
• 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: K
• Authorized Official - Last Name: JACKSON
• 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
• Enumeration Date: 2006-05-17
• Last Update Date: 2013-10-16

Provider Licenses

State	License ID	Taxonomies
KY	17376	207Q00000X
KY	27589	207Q00000X
KY	PA340	363A00000X
KY	PA334	363A00000X
		363AS0400X
KY	3007862	363LF0000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363AS0400X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Surgical	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	C64949	Other	UPIN
KY	331024	Other	ANTHEM
KY	363734	Other	ANTHEM
KY	95003349	Medicaid
KY	6417376800	Medicaid
KY	65922197	Medicaid
KY	K079470	Medicare PIN
KY	K035000	Medicare PIN
	0909705	Medicare PIN
KY	95003349	Medicaid
KY	331024	Other	ANTHEM
KY	363734	Other	ANTHEM
KY	529939	Medicare UPIN
KY	909704	Medicare PIN
KY	0268506	Medicare PIN