Provider Demographics
NPI:1851582688
Name:MY PRIVATE MD PSC
Entity Type:Organization
Organization Name:MY PRIVATE MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PRATHER
Authorized Official - Last Name:RANKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-253-6582
Mailing Address - Street 1:175 S ENGLISH STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4160
Mailing Address - Country:US
Mailing Address - Phone:502-253-6582
Mailing Address - Fax:502-253-6585
Practice Address - Street 1:175 S ENGLISH STATION RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4160
Practice Address - Country:US
Practice Address - Phone:502-253-6582
Practice Address - Fax:502-253-6585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH19902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC68737Medicare UPIN