Provider Demographics
NPI:1598798407
Name:CCMH CORPORATION
Entity Type:Organization
Organization Name:CCMH CORPORATION
Other - Org Name:WARSAW FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-732-3278
Mailing Address - Street 1:309 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008-1435
Mailing Address - Country:US
Mailing Address - Phone:502-732-3230
Mailing Address - Fax:502-732-3297
Practice Address - Street 1:202 FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:KY
Practice Address - Zip Code:41095
Practice Address - Country:US
Practice Address - Phone:859-567-2754
Practice Address - Fax:859-567-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18145207Q00000X
IN01031469207Q00000X
261QR1300X
KY23459363L00000X
KY3284P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100156490Medicaid
KY50030472OtherPASSPORT
KY000000697014OtherANTHEM
KY7100145920Medicaid
KY50030472OtherPASSPORT
INM100063401Medicare PIN
KY000000697014OtherANTHEM