Provider Demographics
NPI:1821425711
Name:PHYSICIANS MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:PHYSICIANS MEDICAL CENTER LLC
Other - Org Name:PMC SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-206-7624
Mailing Address - Street 1:4023 REAS LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2228
Mailing Address - Country:US
Mailing Address - Phone:812-206-7660
Mailing Address - Fax:812-206-7650
Practice Address - Street 1:3605 NORTHGATE CT
Practice Address - Street 2:SUITE 204
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6400
Practice Address - Country:US
Practice Address - Phone:812-207-2130
Practice Address - Fax:812-207-2140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200916560Medicaid
KY7100073940Medicaid