Provider Demographics
NPI:1144270018
Name:PAIGE PRIMARY CARE CENTER
Entity type:Organization
Organization Name:PAIGE PRIMARY CARE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:DAMON
Authorized Official - Last Name:PAIGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-225-4480
Mailing Address - Street 1:1023 NEW MOODY LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9177
Mailing Address - Country:US
Mailing Address - Phone:502-225-4480
Mailing Address - Fax:502-225-9169
Practice Address - Street 1:1023 NEW MOODY LN
Practice Address - Street 2:SUITE 201
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9177
Practice Address - Country:US
Practice Address - Phone:502-225-4480
Practice Address - Fax:502-225-9169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 363LF0000X, 208000000X
KY41864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYD0433OtherMEDICARE RR
KY7100169030Medicaid
7839Medicare ID - Type Unspecified
KY7100079410Medicaid