=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487757134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY G. SKAGGS MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 WALLACE AVE SUITE 105
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-230-0251
-----------------------------------------------------
Fax | 270-230-0712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 WALLACE AVE SUITE 105
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-2404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-230-0251
-----------------------------------------------------
Fax | 270-230-0712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MT
-----------------------------------------------------
Name | MS. TAMI L HART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-230-0251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 24093
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------