=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740407667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCMD, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 06/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1340 ELLIS PLACE
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-782-6362
-----------------------------------------------------
Fax | 270-796-2800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1340 ELLIS PLACE
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-782-6362
-----------------------------------------------------
Fax | 270-796-2800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETORSHIP
-----------------------------------------------------
Name | DR. MICHAEL JOHN COLLINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-782-6362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 19109
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------