Provider Demographics
NPI:1841301520
Name:THACKER FAMILY MEDICAL, PLLC
Entity type:Organization
Organization Name:THACKER FAMILY MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHADWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-432-0191
Mailing Address - Street 1:189 HIBBARD ST
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1754
Mailing Address - Country:US
Mailing Address - Phone:606-432-0191
Mailing Address - Fax:606-432-2028
Practice Address - Street 1:189 HIBBARD ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1754
Practice Address - Country:US
Practice Address - Phone:606-432-0191
Practice Address - Fax:606-432-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38711208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64092638Medicaid
KYH79647Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
KY64092638Medicaid