Provider Demographics
NPI:1992965032
Name:PARKWAY MEDICAL CLINIC
Entity type:Organization
Organization Name:PARKWAY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-598-5115
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-0369
Mailing Address - Country:US
Mailing Address - Phone:606-598-5115
Mailing Address - Fax:606-598-7179
Practice Address - Street 1:454 MANCHESTER SQUARE SHPG CTR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-8781
Practice Address - Country:US
Practice Address - Phone:606-598-5115
Practice Address - Fax:606-598-7179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65920480Medicaid