Healthcare Provider Details

I. General information

NPI: 1821392515
Provider Name (Legal Business Name): SOUTHERN KENTUCKY MEDICAL ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 JOE T. PETTEY DR
RUSSELL SPRINGS KY
42642
US

IV. Provider business mailing address

PO BOX 1383
RUSSELL SPRINGS KY
42642-1383
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-4357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGELA CUNDIFF-ROY
Title or Position: PRESIDENT
Credential:
Phone: 270-866-4357