Healthcare Provider Details

I. General information

NPI: 1275554016
Provider Name (Legal Business Name): SOUTHERN MEDICAL PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 ROY CAMPBELL DR
HAZARD KY
41701-9485
US

IV. Provider business mailing address

277 ROY CAMPBELL DR
HAZARD KY
41701-9485
US

V. Phone/Fax

Practice location:
  • Phone: 606-435-1708
  • Fax: 606-435-2445
Mailing address:
  • Phone: 606-435-1708
  • Fax: 606-435-2445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number34644
License Number StateKY

VIII. Authorized Official

Name: MR. BENNY RAY BAILEY II
Title or Position: CEO
Credential:
Phone: 606-435-1708