Provider Demographics
NPI:1750610663
Name:MEADOWVIEW PHYSICIAN PRACTICE LLC
Entity type:Organization
Organization Name:MEADOWVIEW PHYSICIAN PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1556
Mailing Address - Street 1:901 KENTON STATION DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9609
Mailing Address - Country:US
Mailing Address - Phone:606-759-5337
Mailing Address - Fax:606-759-5340
Practice Address - Street 1:901 KENTON STATION DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9609
Practice Address - Country:US
Practice Address - Phone:606-759-5337
Practice Address - Fax:606-759-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-24
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100142790Medicaid
KY7100142790Medicaid
KY00922Medicare PIN