Provider Demographics
NPI:1740077163
Name:SUPPORTIVE MED
Entity type:Organization
Organization Name:SUPPORTIVE MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-636-8428
Mailing Address - Street 1:250 COLVIN LN
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1286
Mailing Address - Country:US
Mailing Address - Phone:606-371-2369
Mailing Address - Fax:
Practice Address - Street 1:1619 DIEDERICH BLVD STE B
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1779
Practice Address - Country:US
Practice Address - Phone:606-324-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty