Basic Information
| Provider Information | |||||||||
| NPI: | 1275590093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KENTUCKY PRIMARY CARE ASSOCIATES PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1911 CAMPBELLSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427437758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709322424 | ||||||||
| FaxNumber: | 2709322522 | ||||||||
| Practice Location | |||||||||
| Address1: | 1911 CAMPBELLSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427437758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709322424 | ||||||||
| FaxNumber: | 2709322522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | BILLS | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2709322424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78904893 | 05 | KY | MEDICAID |