Provider Demographics
NPI:1578090403
Name:ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON
Entity Type:Organization
Organization Name:ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHURSHEED
Authorized Official - Middle Name:AKRAM
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-691-0201
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40423-2369
Mailing Address - Country:US
Mailing Address - Phone:606-392-2060
Mailing Address - Fax:606-655-1030
Practice Address - Street 1:79 SARAHS LN
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2789
Practice Address - Country:US
Practice Address - Phone:859-691-0201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28741207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65942906Medicaid