Provider Demographics
NPI:1497938583
Name:MCCREARY PRIMARY CARE CENTER, INC
Entity Type:Organization
Organization Name:MCCREARY PRIMARY CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-578-4822
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-0000
Mailing Address - Country:US
Mailing Address - Phone:606-376-2224
Mailing Address - Fax:606-376-2205
Practice Address - Street 1:65 CENTER AVE
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-0000
Practice Address - Country:US
Practice Address - Phone:606-376-2224
Practice Address - Fax:606-376-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02506207R00000X
261Q00000X, 261QR1300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100029190Medicaid
KY7100300430Medicaid
KY000000597415OtherANTHEM
KY188924Medicare Oscar/Certification