Provider Demographics
NPI:1932237211
Name:PROUDFOOT & ASSOCIATES, PSC
Entity Type:Organization
Organization Name:PROUDFOOT & ASSOCIATES, PSC
Other - Org Name:CAVE RUN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHARLET
Authorized Official - Middle Name:N
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-784-9142
Mailing Address - Street 1:PO BOX 1145
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-5145
Mailing Address - Country:US
Mailing Address - Phone:606-783-7689
Mailing Address - Fax:606-784-5671
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-783-7689
Practice Address - Fax:606-784-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24696208800000X
KY39293208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65901597Medicaid
KY65901597Medicaid