NPIMap

Organization Active NPI

Southern Kentucky Primary Care, P.S.C.

  • Rural Health Clinic/Center
  • Russellville, KY
National Provider Identifier
1003327412
Registry record updated Jun 15, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHERN KENTUCKY PRIMARY CARE, P.S.C.
Practice address
101 W 2ND St
Russellville, KY 42276
Phone
(270) 881-1813
Fax
(270) 886-6600
NPI assigned
Oct 12, 2017
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Latisha Edmonds
Title
Office Administrator
Phone
(270) 265-2574

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Geeta S Chavda, MD
    • Internal Medicine Physician
    • Hopkinsville, KY
    • NPI 1962477133

    5% Or Greater Direct Ownership Interest, Corporate Officer, W-2 Managing Employee

    CMS ownership
  • Sanjay M Chavda, MD
    • Pulmonary Disease Physician
    • Hopkinsville, KY
    • NPI 1437124484

    5% Or Greater Direct Ownership Interest, Corporate Director, W-2 Managing Employee

    CMS ownership

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
18D2144252Southern Kentucky Primary Care, PSC101 W 2ND Street, Russellville, KY 42276Certificate of waiverFeb 12, 2028

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20171121002602 KY Part a Provider - Rural Health Clinic 7012274319 Practice locations: Russellville, KY
O20180410002716 KY Part B Supplier - Clinic/Group Practice 7012274319 Receives reassigned benefits from 10 practitioners
Practice locations: Russellville, KY

Rural health clinic certification: CCN 188982

Medicare enrollment files
Legal name
SOUTHERN KENTUCKY PRIMARY CARE PSC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 21, 2018
Last certification
Jun 21, 2018
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
Nov 1, 2017 in KY
Enrollment address
101 W 2ND St
Russellville, KY 42276-1302

All disclosed owners & managing parties 2

Medicare enrollment files

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Sanjay M Chavda Individual 5% Or Greater Direct Ownership Interest Nov 1, 2017 50%
Corporate DirectorDirector Nov 1, 2017
W-2 Managing Employee Nov 1, 2017
Geeta S Chavda Individual 5% Or Greater Direct Ownership Interest Nov 1, 2017 50%
Corporate OfficerCeo Nov 1, 2017
W-2 Managing Employee Nov 1, 2017

National Provider Directory

National Provider Directory

Locations

101 W 2nd St
Russellville, KY 42276
Phone (270) 725-8200

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X KY
Rural Health Clinic/Center 261QR1300X Primary

Addresses

NPPES NPI Registry

Primary practice location

101 W 2ND St
Russellville, KY 42276

Mailing address

1739 Canton St
Hopkinsville, KY 42240-1991
Phone (270) 881-1813

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jun 15, 2018.

{
    "created_epoch": "1507766400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529020800000",
    "number": "1003327412",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1739 CANTON ST",
            "city": "HOPKINSVILLE",
            "state": "KY",
            "postal_code": "422401991",
            "telephone_number": "270-881-1813",
            "fax_number": "270-886-6008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 W 2ND ST",
            "city": "RUSSELLVILLE",
            "state": "KY",
            "postal_code": "42276",
            "telephone_number": "270-881-1813",
            "fax_number": "270-886-6600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN KENTUCKY PRIMARY CARE, P.S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-10-12",
        "last_updated": "2018-06-15",
        "status": "A",
        "authorized_official_last_name": "EDMONDS",
        "authorized_official_first_name": "LATISHA",
        "authorized_official_title_or_position": "OFFICE ADMINISTRATOR",
        "authorized_official_telephone_number": "270-265-2574"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "KY",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Russellville, KY

Sources for this page

Verify at the official NPI Registry.