Provider Demographics
NPI:1508196262
Name:SOUTHERN KY MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHERN KY MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CANP
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNDIFF / ROY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN , CANP
Authorized Official - Phone:270-866-4357
Mailing Address - Street 1:72 JOE T PETTY DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42718
Mailing Address - Country:US
Mailing Address - Phone:270-866-4357
Mailing Address - Fax:270-858-4957
Practice Address - Street 1:72 JOE T PETTY DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42718
Practice Address - Country:US
Practice Address - Phone:270-866-4357
Practice Address - Fax:270-858-4957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2287P364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty