Provider Demographics
NPI:1841373412
Name:MAYSVILLE INTERNAL MEDICINE PEDIATRIC ASSOC PSC
Entity type:Organization
Organization Name:MAYSVILLE INTERNAL MEDICINE PEDIATRIC ASSOC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WALLINGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-759-7615
Mailing Address - Street 1:2009 OLD MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056
Mailing Address - Country:US
Mailing Address - Phone:606-759-7615
Mailing Address - Fax:606-759-7821
Practice Address - Street 1:2009 OLD MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056
Practice Address - Country:US
Practice Address - Phone:606-759-7615
Practice Address - Fax:606-759-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208000000X, 363LF0000X
KY24430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933012Medicaid
C78288OtherDR WALLINGFORDS UPIN
KY7100379280Medicaid
KY02529Medicare PIN