Provider Demographics
NPI:1659554079
Name:MARSHALL COUNTY FAMILY MEDICAL CENTER NURSE PRACTITIONER GROUP
Entity Type:Organization
Organization Name:MARSHALL COUNTY FAMILY MEDICAL CENTER NURSE PRACTITIONER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-527-2273
Mailing Address - Street 1:145 VINE ST
Mailing Address - Street 2:PO BOX 569
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7472
Mailing Address - Country:US
Mailing Address - Phone:270-527-2273
Mailing Address - Fax:
Practice Address - Street 1:145 VINE ST # 569
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7472
Practice Address - Country:US
Practice Address - Phone:270-527-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARSHALL COUNTY FAMILY MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4072P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1689710899OtherNPI INDIVIDUAL
KY1891878641OtherNPI INDIVIDUAL
KY78900180Medicaid
KY1619907870OtherNPI INDIVIDUAL
KY1891878641OtherNPI INDIVIDUAL