Provider Demographics
NPI:1871626820
Name:LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS PSC
Entity type:Organization
Organization Name:LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-234-9611
Mailing Address - Street 1:1210 KY HIGHWAY 36E
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031
Mailing Address - Country:US
Mailing Address - Phone:859-234-9611
Mailing Address - Fax:
Practice Address - Street 1:254 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:KY
Practice Address - Zip Code:40311-1156
Practice Address - Country:US
Practice Address - Phone:859-289-6311
Practice Address - Fax:859-289-3366
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208000000X, 363LF0000X
KYPA783363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65934341Medicaid
KY6735Medicare PIN