Provider Demographics
NPI:1740407667
Name:MCMD, PSC
Entity Type:Organization
Organization Name:MCMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETORSHIP
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-782-6362
Mailing Address - Street 1:1340 ELLIS PLACE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-782-6362
Mailing Address - Fax:270-796-2800
Practice Address - Street 1:1340 ELLIS PLACE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-782-6362
Practice Address - Fax:270-796-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
KY19109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY641910Medicaid
KY00186Medicare PIN