Provider Demographics
NPI:1952334054
Name:FAMILY CARE OF NORTHERN KENTUCKY, PLLC
Entity Type:Organization
Organization Name:FAMILY CARE OF NORTHERN KENTUCKY, PLLC
Other - Org Name:PREMIER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:WECKENBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-341-5757
Mailing Address - Street 1:830 THOMAS MORE PKWY
Mailing Address - Street 2:STE 203
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5102
Mailing Address - Country:US
Mailing Address - Phone:859-341-5757
Mailing Address - Fax:859-331-4757
Practice Address - Street 1:830 THOMAS MORE PKWY
Practice Address - Street 2:STE 203
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5102
Practice Address - Country:US
Practice Address - Phone:859-341-5757
Practice Address - Fax:859-331-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65944027Medicaid
OH2622871Medicaid
KY9701Medicare PIN