Provider Demographics
NPI:1548379779
Name:TOMPKINSVILLE PRIMARY CARE
Entity Type:Organization
Organization Name:TOMPKINSVILLE PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-487-0551
Mailing Address - Street 1:901 N MAIN ST
Mailing Address - Street 2:BOX 476
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-1004
Mailing Address - Country:US
Mailing Address - Phone:270-487-0551
Mailing Address - Fax:270-487-0841
Practice Address - Street 1:901 N MAIN ST
Practice Address - Street 2:BOX 476
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-1004
Practice Address - Country:US
Practice Address - Phone:270-487-0551
Practice Address - Fax:270-487-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934713Medicaid
KYG23559Medicare UPIN