Provider Demographics
NPI:1629346945
Name:SOUTH KENTUCKY PHYSICIAN SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTH KENTUCKY PHYSICIAN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEDFORD
Authorized Official - Last Name:PARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-634-1921
Mailing Address - Street 1:1597 BLISS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-8510
Mailing Address - Country:US
Mailing Address - Phone:270-634-1921
Mailing Address - Fax:
Practice Address - Street 1:202-206 MILBY STREET
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743
Practice Address - Country:US
Practice Address - Phone:270-634-1921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64252638Medicaid