MEDICARE: MONROE MEDICAL FOUNDATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0158	OTHER		MEDICARE

General Provider Information

NPI Number	:	1871052001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONROE MEDICAL FOUNDATION, INC.

Provider Business Mailing Address
First Line	:	529 CAPP HARLAN RD
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-1840
Country	:	US
Telephone Number	:	270-487-9231
Fax Number	:

Provider Business Practice Location Address
First Line	:	529 CAPP HARLAN RD
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-1840
Country	:	US
Telephone Number	:	270-487-9231
Fax Number	:	270-487-5784

Authorized Official
Title or Position	:	ASSISTANT CHIEF FINANCIAL OFFICER
Name	:	ALISA NICHOLE MELTON
Credential	:
Telephone Number	:	270-487-9231

Provider Enumeration Date	:	03/18/2019
Last Update Date	:	03/18/2019

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