Provider Demographics
NPI:1962432153
Name:GLENN R. WOMACK M.D. PSC
Entity type:Organization
Organization Name:GLENN R. WOMACK M.D. PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-849-2323
Mailing Address - Street 1:732 ELIZAVILLE ROAD
Mailing Address - Street 2:PO BOX 344
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041
Mailing Address - Country:US
Mailing Address - Phone:606-849-2323
Mailing Address - Fax:606-849-2025
Practice Address - Street 1:732 ELIZAVILLE ROAD
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041
Practice Address - Country:US
Practice Address - Phone:606-849-2323
Practice Address - Fax:606-849-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78904141Medicaid
KY9590108800Medicaid
KY65929143Medicaid
KY9590108800Medicaid