Provider Demographics
NPI:1629342985
Name:THACKER FAMILY MEDICAL LLC
Entity Type:Organization
Organization Name:THACKER FAMILY MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOILE MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHADWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-509-2000
Mailing Address - Street 1:PO BOX 1228
Mailing Address - Street 2:140 ADAMS LANE, SUITE 600-700
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1228
Mailing Address - Country:US
Mailing Address - Phone:606-509-2000
Mailing Address - Fax:606-509-2002
Practice Address - Street 1:140 ADAMS LN
Practice Address - Street 2:SUITE 600-700
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3087
Practice Address - Country:US
Practice Address - Phone:606-509-2000
Practice Address - Fax:606-509-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty