Provider Demographics
NPI:1982659496
Name:ANDERSON PRIMARY CARE LLC
Entity Type:Organization
Organization Name:ANDERSON PRIMARY CARE LLC
Other - Org Name:PRIMARY CARE EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-219-2828
Mailing Address - Street 1:1055 WELLINGTON WAY
Mailing Address - Street 2:SUITE 275
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1259
Mailing Address - Country:US
Mailing Address - Phone:859-219-2828
Mailing Address - Fax:859-219-0524
Practice Address - Street 1:1055 CORPORATE DRIVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342
Practice Address - Country:US
Practice Address - Phone:502-839-5590
Practice Address - Fax:502-839-3450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208D00000X
KY700156261QP2300X
KY363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31001068Medicaid
KY00053Medicare ID - Type Unspecified
KY00053Medicare PIN