Healthcare Provider Details

I. General information

NPI: 1730473745
Provider Name (Legal Business Name): MADISON PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SAINT GEORGE ST SUITE 110
RICHMOND KY
40475-2376
US

IV. Provider business mailing address

1031 WELLINGTON WAY STE 240
LEXINGTON KY
40513-1257
US

V. Phone/Fax

Practice location:
  • Phone: 859-626-9766
  • Fax: 859-626-0741
Mailing address:
  • Phone: 859-303-8746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number900242
License Number StateKY

VIII. Authorized Official

Name: BRITTANY UNDERWOOD
Title or Position: CREDENTIALING
Credential:
Phone: 859-303-8746