Provider Demographics
NPI:1710019674
Name:TATES CREEK FAMILY PRACTICE, PLC
Entity Type:Organization
Organization Name:TATES CREEK FAMILY PRACTICE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-273-3888
Mailing Address - Street 1:4071 TATES CREEK CENTRE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3062
Mailing Address - Country:US
Mailing Address - Phone:859-273-3888
Mailing Address - Fax:859-977-0170
Practice Address - Street 1:4071 TATES CREEK CENTRE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-3062
Practice Address - Country:US
Practice Address - Phone:859-273-3888
Practice Address - Fax:859-977-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8727Medicare ID - Type UnspecifiedMEDICARE GROUP
KY9191Medicare ID - Type UnspecifiedMEDICARE GROUP
KY5471Medicare ID - Type UnspecifiedMEDICARE GROUP
KY8736Medicare ID - Type UnspecifiedMEDICARE GROUP