Provider Demographics
NPI:1639346844
Name:EDDYVILLE FAMILY MEDICAL
Entity type:Organization
Organization Name:EDDYVILLE FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLENDENING
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-388-0620
Mailing Address - Street 1:209 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-7752
Mailing Address - Country:US
Mailing Address - Phone:270-388-0620
Mailing Address - Fax:270-388-0604
Practice Address - Street 1:209 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42038-7752
Practice Address - Country:US
Practice Address - Phone:270-388-0620
Practice Address - Fax:270-388-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1910P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78901758Medicaid