Provider Demographics
NPI:1568443422
Name:EAST KENTUCKY MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:EAST KENTUCKY MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-432-2172
Mailing Address - Street 1:50 WEDDINGTON BRANCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3296
Mailing Address - Country:US
Mailing Address - Phone:606-432-2172
Mailing Address - Fax:606-433-0143
Practice Address - Street 1:50 WEDDINGTON BRANCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3296
Practice Address - Country:US
Practice Address - Phone:606-432-2172
Practice Address - Fax:606-433-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100105940Medicaid
KY3722Medicare PIN
KY7100105940Medicaid