Healthcare Provider Details

I. General information

NPI: 1336563543
Provider Name (Legal Business Name): ADVANCED INTERNAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 BROADWAY ST
PADUCAH KY
42001-7107
US

IV. Provider business mailing address

2005 BROADWAY ST
PADUCAH KY
42001-7107
US

V. Phone/Fax

Practice location:
  • Phone: 270-366-7650
  • Fax: 270-443-0660
Mailing address:
  • Phone: 270-366-7650
  • Fax: 270-443-0600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN CURTIS FRAZINE
Title or Position: SOLE MEMBER
Credential: MD
Phone: 270-994-2625