Provider Demographics
NPI:1609452929
Name:PROACTIVE MD KY PSC
Entity Type:Organization
Organization Name:PROACTIVE MD KY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP FINANCE & ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-501-0715
Mailing Address - Street 1:124 ALLAWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6207
Mailing Address - Country:US
Mailing Address - Phone:864-501-0751
Mailing Address - Fax:
Practice Address - Street 1:124 ALLAWOOD CT
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-6207
Practice Address - Country:US
Practice Address - Phone:864-501-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-18
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty