Provider Demographics
NPI:1639131246
Name:PURCHASE GASTROENTEROLOGY ASSOCIATES PSC
Entity Type:Organization
Organization Name:PURCHASE GASTROENTEROLOGY ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LASHAEY
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-251-4575
Mailing Address - Street 1:1029 MEDICAL CENTER CIRCLE
Mailing Address - Street 2:STE 306
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066
Mailing Address - Country:US
Mailing Address - Phone:270-251-4575
Mailing Address - Fax:270-251-4577
Practice Address - Street 1:1029 MEDICAL CENTER CIRCLE
Practice Address - Street 2:STE 306
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066
Practice Address - Country:US
Practice Address - Phone:270-251-4575
Practice Address - Fax:270-251-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30255207RG0100X
KY41420207RG0100X
KY3005111363LF0000X
KY3004998364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943284Medicaid
KY7100234660Medicaid
KY9585Medicare PIN