Provider Demographics
NPI:1467454041
Name:FAMILY PRACTICE CLINIC PSC
Entity type:Organization
Organization Name:FAMILY PRACTICE CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:MADDUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-965-5238
Mailing Address - Street 1:PO BOX 559
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-0559
Mailing Address - Country:US
Mailing Address - Phone:270-965-5238
Mailing Address - Fax:270-965-9015
Practice Address - Street 1:518 WEST GUM STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1516
Practice Address - Country:US
Practice Address - Phone:270-965-5238
Practice Address - Fax:270-965-9015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65905770Medicaid
KY78900719Medicaid
KY65905770Medicaid
KY2761Medicare ID - Type Unspecified
KYC10742Medicare ID - Type UnspecifiedRAILROAD MEDICARE