Provider Demographics
NPI:1043346562
Name:EASTERN KY HEATLHCARE CENTER
Entity type:Organization
Organization Name:EASTERN KY HEATLHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-478-4287
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:MINNIE
Mailing Address - State:KY
Mailing Address - Zip Code:41651-0100
Mailing Address - Country:US
Mailing Address - Phone:606-478-4287
Mailing Address - Fax:606-478-4288
Practice Address - Street 1:8535 KY RT 122
Practice Address - Street 2:
Practice Address - City:MINNIE
Practice Address - State:KY
Practice Address - Zip Code:41651
Practice Address - Country:US
Practice Address - Phone:606-478-4287
Practice Address - Fax:606-478-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYANTHEM BLUE CROSSOther000000336367
KYDD7592OtherPALMETTO GBA
KY65941668Medicaid
KYDD7592OtherPALMETTO GBA
KYE85865Medicare UPIN
KY65941668Medicaid