Active NPI
Advanced Family Medical Clinic Liberty
- Rural Health Clinic/Center
- Liberty, KY
National Provider Identifier
1023545241
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- ADVANCED FAMILY MEDICAL CLINIC LIBERTY
- Practice address
- 84 Hustonville St
Liberty, KY 42539-3469 - Phone
- (606) 706-7473
- Fax
- (606) 303-9170
- NPI assigned
- May 18, 2017
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Khursheed Akram Siddiqui, MD
- Title
- Medical Director
- Phone
- (859) 691-0201
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 28741 | KY | |
| Rural Health Clinic/Center | 261QR1300X | Primary |
Addresses
Primary practice location
84 Hustonville St
Liberty, KY 42539-3469
Mailing address
PO Box 2369
Danville, KY 40423-2369
Phone (606) 303-9011
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7100503210 | Medicaid | KY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in KY
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170620000387 | KY | Part A Provider - Rural Health Clinic | 3173891926 | Practice locations: Liberty, KY |
| O20171026003580 | KY | Part B Supplier - Clinic/Group Practice | 3173891926 |
Receives reassigned benefits from 11 practitioners Practice locations: Liberty, KY |
Rural health clinic certification: CCN 188970
- Legal name
- ADVANCED FAMILY MEDICAL CLINIC LIBERTY
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Dec 27, 2017
- Last certification
- Apr 13, 2021
- Ownership / control type
- 1B
- Organization structure
- LLC
- Enrollment address
- 84 Hustonville St
Liberty, KY 42539-3456
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D2169807 | Advanced Family Medical Clinic of Liberty | Certificate of waiver | Jul 28, 2027 |
National Provider Directory
National Provider DirectoryLocations
84 Hustonville St
Liberty, KY 42539
Phone (606) 303-9011
Ownership & related parties
All disclosed owners & managing parties 2
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Khursheed Akram Siddiqui | 5% Or Greater Direct Ownership Interest | May 15, 2017 | 50% |
| Corporate Officer | May 15, 2017 | ||
| W-2 Managing Employee | May 15, 2017 | ||
| Operational/Managerial Control | May 15, 2017 | ||
| Sheba M Siddiqui | 5% Or Greater Direct Ownership Interest | Jun 17, 2017 | 50% |
| Corporate Officer | May 15, 2017 | ||
| Operational/Managerial Control | May 15, 2017 |
Owners & managing parties with NPI records 1
Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.
-
- Pain Medicine Physician
- Danville, KY
- NPI 1881634368
5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control, W-2 Managing Employee
Practitioners & affiliated clinicians
Practitioners 11
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1495065600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1768521600000",
"number": "1023545241",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 2369",
"city": "DANVILLE",
"state": "KY",
"postal_code": "404232369",
"telephone_number": "606-303-9011",
"fax_number": "606-303-9170"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "84 HUSTONVILLE ST",
"city": "LIBERTY",
"state": "KY",
"postal_code": "425393469",
"telephone_number": "606-706-7473",
"fax_number": "606-303-9170"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "ADVANCED FAMILY MEDICAL CLINIC LIBERTY",
"organizational_subpart": "NO",
"enumeration_date": "2017-05-18",
"last_updated": "2026-01-16",
"certification_date": "2026-01-16",
"status": "A",
"authorized_official_last_name": "SIDDIQUI",
"authorized_official_first_name": "KHURSHEED",
"authorized_official_middle_name": "AKRAM",
"authorized_official_title_or_position": "MEDICAL DIRECTOR",
"authorized_official_telephone_number": "859-691-0201",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Family Medicine",
"state": "KY",
"license": "28741",
"primary": false
},
{
"code": "261QR1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Rural Health",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "7100503210",
"state": "KY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Liberty, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.