Provider Demographics
NPI:1336348523
Name:KENTUCKY MOUNTAIN EMERGENCY PHYSICIANS
Entity Type:Organization
Organization Name:KENTUCKY MOUNTAIN EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVASNIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-355-0808
Mailing Address - Street 1:PO BOX 42966
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-2966
Mailing Address - Country:US
Mailing Address - Phone:800-355-0808
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-8511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000332890OtherBLUE SHIELD
KY65943375Medicaid
KY9400Medicare PIN