Provider Demographics
NPI:1316143845
Name:VINE GROVE FAMILY MEDICINE PSC
Entity type:Organization
Organization Name:VINE GROVE FAMILY MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAW
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:270-877-6672
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-1302
Mailing Address - Country:US
Mailing Address - Phone:270-877-6672
Mailing Address - Fax:
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1302
Practice Address - Country:US
Practice Address - Phone:270-877-6672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty