Provider Demographics
NPI:1265621213
Name:MOUNTAIN VIEW FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:MOUNTAIN VIEW FAMILY PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:KREIS
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:606-877-2850
Mailing Address - Street 1:272 LONDON MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-6601
Mailing Address - Country:US
Mailing Address - Phone:606-877-2850
Mailing Address - Fax:606-877-2857
Practice Address - Street 1:272 LONDON MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-6601
Practice Address - Country:US
Practice Address - Phone:606-877-2850
Practice Address - Fax:606-877-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100140520Medicaid
KY65944589Medicaid
KYP00278839OtherRAILROAD MEDICARE
KYDE2149OtherRAILROAD MEDICARE
KY9927Medicare PIN