Provider Demographics
NPI:1982891057
Name:CCMH CORPORATION
Entity Type:Organization
Organization Name:CCMH CORPORATION
Other - Org Name:BEDFORD FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-732-3278
Mailing Address - Street 1:470 HIGHWAY 421 N
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40006-8690
Mailing Address - Country:US
Mailing Address - Phone:502-255-7732
Mailing Address - Fax:
Practice Address - Street 1:309 11TH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-1435
Practice Address - Country:US
Practice Address - Phone:502-662-0336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY900261261QR1300X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50014776OtherPASSPORT
KY7100010810Medicaid
KY000000520562OtherANTHEM
KY188919Medicare PIN
KY50014776OtherPASSPORT