=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891813986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRACTICE OF GREENVILLE PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 01/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 GREENE DR
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42345-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-338-0600
-----------------------------------------------------
Fax | 270-338-0605
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 GREENE DR FAMILY PRACTICE OF GREENVILLE PSC
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42345-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-338-0600
-----------------------------------------------------
Fax | 270-338-0605
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO PHYSICIAN OWNER
-----------------------------------------------------
Name | MARSHALL EDWARD PRUNTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 270-338-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 22988
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------