Provider Demographics
NPI:1043318561
Name:DANVILLE MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:DANVILLE MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-936-2020
Mailing Address - Street 1:416A W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422
Mailing Address - Country:US
Mailing Address - Phone:859-936-2020
Mailing Address - Fax:859-936-7424
Practice Address - Street 1:416A W WALNUT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422
Practice Address - Country:US
Practice Address - Phone:859-936-2020
Practice Address - Fax:859-936-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDB4203OtherRAILROAD MEDICARE
KY000000313483OtherBC GROUP #
KY65940082Medicaid
KY65940082Medicaid