Provider Demographics
NPI:1497892103
Name:PADUCAH PRIMARY CARE, P.S.C.
Entity Type:Organization
Organization Name:PADUCAH PRIMARY CARE, P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-442-8575
Mailing Address - Street 1:2601 KENTUCKY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3817
Mailing Address - Country:US
Mailing Address - Phone:270-442-8575
Mailing Address - Fax:270-442-8783
Practice Address - Street 1:4620 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7501
Practice Address - Country:US
Practice Address - Phone:270-442-8575
Practice Address - Fax:270-442-8783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65927717Medicaid
KY65927717Medicaid
KY4929Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER