Healthcare Provider Details

I. General information

NPI: 1255367934
Provider Name (Legal Business Name): PRIMARY CARE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 8TH ST STE 480W
MURRAY KY
42071-2400
US

IV. Provider business mailing address

300 S 8TH ST STE 480W
MURRAY KY
42071-2400
US

V. Phone/Fax

Practice location:
  • Phone: 270-759-9200
  • Fax: 270-759-9966
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number22158
License Number StateKY

VIII. Authorized Official

Name: DIRENDIA SHACKELFORD
Title or Position: MANAGED CARE SPEC ALLSCRIPTS
Credential:
Phone: 800-654-0889