Provider Demographics
NPI:1992254288
Name:JACKSON PURCHASE PULMONARY MEDICINE PLLC
Entity type:Organization
Organization Name:JACKSON PURCHASE PULMONARY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-251-4040
Mailing Address - Street 1:1111 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1194
Mailing Address - Country:US
Mailing Address - Phone:270-251-4040
Mailing Address - Fax:855-430-0335
Practice Address - Street 1:1111 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1194
Practice Address - Country:US
Practice Address - Phone:270-251-4040
Practice Address - Fax:855-430-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100399120Medicaid
KYK173240Medicare Oscar/Certification