Provider Demographics
NPI:1518992023
Name:APPALACHIAN PHYSICIANS PSC
Entity Type:Organization
Organization Name:APPALACHIAN PHYSICIANS PSC
Other - Org Name:APPALACHIAN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-279-2771
Mailing Address - Street 1:509 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:5923 HWY 80
Practice Address - Street 2:
Practice Address - City:WOOTON
Practice Address - State:KY
Practice Address - Zip Code:41776
Practice Address - Country:US
Practice Address - Phone:606-598-5104
Practice Address - Fax:606-598-0983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY183932Medicare Oscar/Certification