NPIMap

Individual provider Active NPI

Jack D Anderson, DO

  • Family Medicine Physician
  • Tompkinsville, KY
National Provider Identifier
1245527969
Registry record updated Jun 10, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
03464 Issued in KY
Practice address
1515 Edmonton Rd
Tompkinsville, KY 42167-9402
Phone
(270) 487-9272
Fax
(270) 487-6242
NPI assigned
Jul 1, 2011
Last updated
Jun 10, 2014By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 10, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 03464 KY Primary

Addresses

Primary practice location

1515 Edmonton Rd
Tompkinsville, KY 42167-9402

Mailing address

PO Box 1080
Burkesville, KY 42717-1080
Phone (270) 864-1472

Other identifiers 1

IdentifierTypeStateIssuer
7100197370MedicaidKY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110810000138 KY Practitioner - Family Practice 6103095062 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Pikeville, Kentucky College of Osteopathic Med, 2010
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Monroe Medical Foundation, Inc.Group PAC ID 5092702472, 30 clinicians

Practice addresses (Care Compare)

1515 Edmonton Rd
Tompkinsville, KY 42167-9402
Phone (270) 487-9272

529 Capp Harlan Rd
Tompkinsville, KY 42167-1808
Phone 27048792311199

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy

Practice roles

OrganizationSpecialtyStatusNew patients
Monroe Medical Foundation, Inc. Family Medicine CurrentSince Jul 1, 2011 Accepting new patients
Cumberland Family Medical Center Inc Current Accepting new patients
Cumberland Family Medical Center Inc CurrentSince Apr 25, 2016 Accepting new patients
Cumberland Family Medical Center Inc CurrentSince Apr 25, 2016 Accepting new patients
Monroe Medical Foundation Inc CurrentSince Jul 1, 2011 Accepting new patients
Monroe Medical Foundation, Inc. Past Accepting new patients
Cumberland Family Medical Center Inc Past Accepting new patients
LP Tompkinsville, LLC Past Accepting new patients

Locations

360 Keen St
Burkesville, KY 42717
Phone (270) 864-1472

1515 Edmonton Rd
Tompkinsville, KY 42167
Phone (270) 487-9272

529 Capp Harlan Rd
Tompkinsville, KY 42167
Phone (270) 487-6048

Interoperability endpoints

  • Direct secure messaging: erjda@yourcarecommunity.org
  • FHIR API: https://fhir.meditouchehr.com/api/fhir/r4/

Ownership & related parties

All facility ownership & control disclosures 4

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Monroe County Medical CenterTompkinsville, KY, CCN 180105 Hospital Corporate Director Jan 1, 2023
Monroe County Medical CenterTompkinsville, KY, CCN 18U105 Hospital Corporate Director Jan 1, 2023
Monroe County Physician AssociatesTompkinsville, KY, CCN 188544 Rural health clinic Corporate Director Jan 1, 2023
Monroe County Family PracticeTompkinsville, KY, CCN 188554 Rural health clinic Corporate Director Jan 1, 2023

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1309478400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1402358400000",
    "number": "1245527969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1080",
            "city": "BURKESVILLE",
            "state": "KY",
            "postal_code": "427171080",
            "telephone_number": "270-864-1472",
            "fax_number": "270-864-1693"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1515 EDMONTON RD",
            "city": "TOMPKINSVILLE",
            "state": "KY",
            "postal_code": "421679402",
            "telephone_number": "270-487-9272",
            "fax_number": "270-487-6242"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ANDERSON",
        "first_name": "JACK",
        "middle_name": "D",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-07-01",
        "last_updated": "2014-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "KY",
            "license": "03464",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100197370",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Tompkinsville, KY

Sources for this page

Verify at the official NPI Registry.