Provider Demographics
NPI:1700827599
Name:FAMILY MEDICAL CARE OF MANCHESTER
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF MANCHESTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:GERARDY
Authorized Official - Last Name:IRWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-599-9955
Mailing Address - Street 1:94 MARIE LANGDON DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6353
Mailing Address - Country:US
Mailing Address - Phone:606-599-9955
Mailing Address - Fax:606-599-9966
Practice Address - Street 1:94 MARIE LANGDON DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6353
Practice Address - Country:US
Practice Address - Phone:606-599-9955
Practice Address - Fax:606-599-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC92418OtherCUMBERLAND HEALTHCARE
KY31000813Medicaid
KY020252900OtherBLACK LUNG GROUP #
KY1168920OtherPASSPORT GROUP PROVIDER #
KY000000195439OtherBLUE CROSS/BLUE SHIELD
KY020252900OtherBLACK LUNG GROUP #