Provider Demographics
NPI:1427165869
Name:J. TODD DOUGLAS, MD, PSC
Entity type:Organization
Organization Name:J. TODD DOUGLAS, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-526-2772
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:205 EAST OHIO ST
Mailing Address - City:MORGANTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42261-1367
Mailing Address - Country:US
Mailing Address - Phone:270-526-2772
Mailing Address - Fax:270-526-6323
Practice Address - Street 1:205 E OHIO ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:KY
Practice Address - Zip Code:42261-7944
Practice Address - Country:US
Practice Address - Phone:270-526-2772
Practice Address - Fax:270-526-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34188207Q00000X
KY7100116510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65903239Medicaid
KY64341886Medicaid
KY65903239Medicaid
KYG28780Medicare UPIN