Provider Demographics
NPI:1255788725
Name:AFFINITY HEALTH CARE PSC
Entity type:Organization
Organization Name:AFFINITY HEALTH CARE PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:606-672-1978
Mailing Address - Street 1:22055 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-8568
Mailing Address - Country:US
Mailing Address - Phone:606-672-1978
Mailing Address - Fax:
Practice Address - Street 1:22055 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-8568
Practice Address - Country:US
Practice Address - Phone:606-672-1978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-15
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1086363AM0700X
KY261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100415020Medicaid
KY7100422110Medicaid