Provider Demographics
NPI:1891813986
Name:FAMILY PRACTICE OF GREENVILLE PSC
Entity type:Organization
Organization Name:FAMILY PRACTICE OF GREENVILLE PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PRUNTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-338-0600
Mailing Address - Street 1:601 GREENE DR
Mailing Address - Street 2:FAMILY PRACTICE OF GREENVILLE PSC
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1451
Mailing Address - Country:US
Mailing Address - Phone:270-338-0600
Mailing Address - Fax:270-338-0605
Practice Address - Street 1:601 GREENE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1451
Practice Address - Country:US
Practice Address - Phone:270-338-0600
Practice Address - Fax:270-338-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64229883Medicaid
KY000000048338OtherANTHEM BCBS
080193902OtherRAILROAD MEDICARE
KY64229883Medicaid
KY1846601Medicare ID - Type Unspecified