Provider Demographics
NPI:1255367934
Name:PRIMARY CARE MEDICAL CENTER
Entity type:Organization
Organization Name:PRIMARY CARE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE SPEC ALLSCRIPTS
Authorized Official - Prefix:
Authorized Official - First Name:DIRENDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-654-0889
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:STE 480W
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S 8TH ST
Practice Address - Street 2:STE 480W
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2400
Practice Address - Country:US
Practice Address - Phone:270-759-9200
Practice Address - Fax:270-759-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22158332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1829437OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KY64221583Medicaid