1598798407 NPI number — CCMH CORPORATION

Table of content: (NPI 1598798407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598798407 NPI number — CCMH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCMH CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WARSAW FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598798407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41008-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-732-3230
Provider Business Mailing Address Fax Number:
502-732-3297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 FRANKLIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-567-2754
Provider Business Practice Location Address Fax Number:
859-567-5108
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TOMLINSON
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
502-732-3278

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18145 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 01031469 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 23459 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 3284P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100156490 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50030472 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000697014 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100145920 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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