Healthcare Provider Details

I. General information

NPI: 1295563765
Provider Name (Legal Business Name): PHELPS MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 TRADEPARK DR STE B
SOMERSET KY
42503-3428
US

IV. Provider business mailing address

115 TRADEPARK DR STE B
SOMERSET KY
42503-3428
US

V. Phone/Fax

Practice location:
  • Phone: 606-307-3918
  • Fax:
Mailing address:
  • Phone: 606-307-3918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANA LINDA PHELPS
Title or Position: OWNER
Credential: APRN
Phone: 606-307-3918