Provider Demographics
NPI:1669670816
Name:WAYNESBURG CLINIC, PLLC
Entity Type:Organization
Organization Name:WAYNESBURG CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DUVALL
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-365-1547
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40489-0435
Mailing Address - Country:US
Mailing Address - Phone:606-379-6646
Mailing Address - Fax:606-379-5707
Practice Address - Street 1:14098 US HIGHWAY 27 S
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:KY
Practice Address - Zip Code:40489-8253
Practice Address - Country:US
Practice Address - Phone:606-379-6646
Practice Address - Fax:606-379-5707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900205261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100019500Medicaid
KY00361OtherMEDICARE PART B
KY183954OtherMEDICARE PART A