Provider Demographics
NPI:1932116027
Name:STAT MED P.A.
Entity Type:Organization
Organization Name:STAT MED P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT REP
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:270-744-9600
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-8642
Practice Address - Street 1:902B N AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-4333
Practice Address - Country:US
Practice Address - Phone:521-930-7828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0029NVOtherBCBS
TX0029NVOtherBCBS