Provider Demographics
NPI:1841358876
Name:FIRST YOU MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:FIRST YOU MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:STIVERS DAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-593-0083
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-0124
Mailing Address - Country:US
Mailing Address - Phone:502-593-0083
Mailing Address - Fax:888-310-2675
Practice Address - Street 1:18 ALEXANDER AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:BEDFORD
Practice Address - State:KY
Practice Address - Zip Code:40006-1114
Practice Address - Country:US
Practice Address - Phone:502-255-0222
Practice Address - Fax:888-310-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207Q00000X, 363A00000X
363LF0000X
KY900263261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000265566OtherANTHEM
KY7100244880Medicaid
KYCK7832OtherRAILROAD MEDICARE
KY64127467OtherPHP
KY50002355OtherPASSPORT HEALTH
KY2443866001OtherPASSPORT ADVANTAGE
KY2443866001OtherPASSPORT ADVANTAGE
K092181Medicare PIN