Provider Demographics
NPI:1538280565
Name:GLENN CATLETT PSC & GEORGIANNA CATLETT PTRS
Entity Type:Organization
Organization Name:GLENN CATLETT PSC & GEORGIANNA CATLETT PTRS
Other - Org Name:A GLEN CATLETT & GEORGIANNA CATLETT PTR
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:A
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:CATLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-358-3830
Mailing Address - Street 1:207 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HODGENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42748-1559
Mailing Address - Country:US
Mailing Address - Phone:270-358-3830
Mailing Address - Fax:270-358-9350
Practice Address - Street 1:207 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HODGENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42748-1559
Practice Address - Country:US
Practice Address - Phone:270-358-3830
Practice Address - Fax:270-358-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21010174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00578Medicare PIN