Provider Demographics
NPI:1861453524
Name:CREEKSIDE FAMILY MEDICAL CENTER,PSC
Entity Type:Organization
Organization Name:CREEKSIDE FAMILY MEDICAL CENTER,PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CECIL
Authorized Official - Last Name:CRAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-477-1955
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-0529
Mailing Address - Country:US
Mailing Address - Phone:502-477-1955
Mailing Address - Fax:502-477-5524
Practice Address - Street 1:83 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-8616
Practice Address - Country:US
Practice Address - Phone:502-477-1955
Practice Address - Fax:502-477-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65937534Medicaid
KY0716101Medicare PIN
KYF26767Medicare UPIN