Provider Demographics
NPI:1538295571
Name:MT WASHINGTON FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:MT WASHINGTON FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-955-5800
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-0067
Mailing Address - Country:US
Mailing Address - Phone:502-955-5800
Mailing Address - Fax:502-538-3040
Practice Address - Street 1:532 BARDSTOWN RD N
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047
Practice Address - Country:US
Practice Address - Phone:502-955-5800
Practice Address - Fax:502-538-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64011109Medicaid
KY7088131OtherAETNA
KYDA9753OtherRAILROAD MEDICARE
KY2443395000OtherPASSPORT ADVANTAGE
KY000000306485OtherBCBS
KY0790901Medicare PIN
KY2443395000OtherPASSPORT ADVANTAGE