Provider Demographics
NPI:1801905906
Name:CALDWELL COUNTY MEDICAL CLINIC
Entity type:Organization
Organization Name:CALDWELL COUNTY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT REP
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-744-9600
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-8642
Practice Address - Street 1:323 S JEFFERSON ST
Practice Address - Street 2:SUITE D
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-2100
Practice Address - Country:US
Practice Address - Phone:270-365-4505
Practice Address - Fax:270-365-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65942872Medicaid
KY65942872Medicaid
KY9416Medicare PIN