Provider Demographics
NPI:1760613996
Name:APPALACHIA MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:APPALACHIA MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-565-2425
Mailing Address - Street 1:127 CALLAHAN AVE
Mailing Address - Street 2:
Mailing Address - City:APPALACHIA
Mailing Address - State:VA
Mailing Address - Zip Code:24216-1203
Mailing Address - Country:US
Mailing Address - Phone:276-565-2425
Mailing Address - Fax:
Practice Address - Street 1:127 CALLAHAN AVE
Practice Address - Street 2:
Practice Address - City:APPALACHIA
Practice Address - State:VA
Practice Address - Zip Code:24216-1203
Practice Address - Country:US
Practice Address - Phone:276-565-2425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005639531Medicaid
KY64662299Medicaid
VA080182667Medicare PIN
VA080008020Medicare PIN
VA005639531Medicaid