Provider Demographics
NPI:1770773525
Name:ARCHER CLINIC ASSOCIATES
Entity type:Organization
Organization Name:ARCHER CLINIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HIERONYMUS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:606-886-3887
Mailing Address - Street 1:400 UNIVERSITY DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PRESTONBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653
Mailing Address - Country:US
Mailing Address - Phone:606-886-3888
Mailing Address - Fax:606-886-3818
Practice Address - Street 1:400 UNIVERSITY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PRESTONBURG
Practice Address - State:KY
Practice Address - Zip Code:41653
Practice Address - Country:US
Practice Address - Phone:606-886-3887
Practice Address - Fax:606-886-3818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1002252OtherUNITED MINE WORKERS OF AM
000000046040OtherBLUE CROSS BLUE SHIELD
16846OtherKY LICENSE NUMBER
103141OtherBLACK LUNG
AH5581548OtherDEA LICENSE NUMBER