Organization
LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS PSC
Active
Parent organization
LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS, PSC
Other names
Licking Valley IM PED-Carlisle
Organization subpart
Yes
Provider details
NPI number
Legal business name
LICKING VALLEY INTERNAL MEDICINE & PEDIATRICS, PSC
Authorized official
DONNA MARTIN (OFFICE MANAGER)
(859) 234-9611
Entity
Organization
Contact information
Practice address
254 E MAIN ST, CARLISLE, KY 40311-1156
(859) 289-6311
(859) 289-3366
Mailing address
1210 KY HIGHWAY 36E, SUITE 2A, CYNTHIANA, KY 41031
(859) 234-9611
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
208000000X
Pediatrics Physician
—
—
363A00000X
Physician Assistant
PA783
KY
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
65934341
—
KY
Enumeration date
03/13/2007
Last updated
01/03/2008
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