Healthcare Provider Details

I. General information

NPI: 1497938583
Provider Name (Legal Business Name): MCCREARY PRIMARY CARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CENTER AVE
WHITLEY CITY KY
42653-0000
US

IV. Provider business mailing address

PO BOX 129
WHITLEY CITY KY
42653-0000
US

V. Phone/Fax

Practice location:
  • Phone: 606-376-2224
  • Fax: 606-376-2205
Mailing address:
  • Phone: 606-376-2224
  • Fax: 606-376-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02506
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. KENNETH E ALLISON
Title or Position: PRESIDENT
Credential:
Phone: 859-578-4822