Provider Demographics
NPI:1568475986
Name:CENTRAL KENTUCKY MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:CENTRAL KENTUCKY MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-278-9413
Mailing Address - Street 1:115 CROSSFIELD DR STE A
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1845
Mailing Address - Country:US
Mailing Address - Phone:859-873-9843
Mailing Address - Fax:
Practice Address - Street 1:115 CROSSFIELD DR STE A
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1845
Practice Address - Country:US
Practice Address - Phone:859-873-9843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0765Medicare ID - Type Unspecified