Provider Demographics
NPI:1750582961
Name:J. KELLY PATTERSON, M.D., P.S.C.
Entity type:Organization
Organization Name:J. KELLY PATTERSON, M.D., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-586-5888
Mailing Address - Street 1:208 S MAIN
Mailing Address - Street 2:PO 385
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134
Mailing Address - Country:US
Mailing Address - Phone:270-813-2520
Mailing Address - Fax:270-713-0234
Practice Address - Street 1:208 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134
Practice Address - Country:US
Practice Address - Phone:270-813-2520
Practice Address - Fax:270-713-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64272131Medicaid
KY65929200Medicaid
KY110158592OtherRAILROAD MEDICARE
KY000000049404OtherANTHEM BLUE CROSS
KY000000305382OtherPROVIDER NUMBER
KY18D0712268OtherCLIA NUMBER
KY64272131Medicaid
KY64272131Medicaid