Provider Demographics
NPI:1518016823
Name:PMCP, PSC
Entity type:Organization
Organization Name:PMCP, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAXMAIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-554-8373
Mailing Address - Street 1:2831 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8041
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:2831 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8041
Practice Address - Country:US
Practice Address - Phone:270-554-8373
Practice Address - Fax:270-554-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6592880600Medicaid
IL=========001Medicaid
IL451520Medicare PIN
KY4044Medicare ID - Type UnspecifiedKY MEDICARE
KYCG4034Medicare PIN
KY6592880600Medicaid