Provider Demographics
NPI:1942275805
Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY, LLC
Other - Org Name:PRIMARY CARE CENTERS OF EASTERN KENTUCKY-HAZARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-439-1300
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702
Mailing Address - Country:US
Mailing Address - Phone:606-435-7642
Mailing Address - Fax:606-436-5282
Practice Address - Street 1:101 TOWN AND COUNTRY LN
Practice Address - Street 2:SUITE100
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-439-1300
Practice Address - Fax:606-439-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900161261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100167330Medicaid
KY7763Medicare PIN
KY7100167330Medicaid