Williamsburg Family Medicine Center
Organization Active NPI Rural Health Clinic/Center · Williamsburg, KY
NPI 1376689620 · NPPES record last updated Dec 15, 2023
Key facts
- NPI
- 1376689620
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 900065 (KY)
- Legal business name
- WILLIAMSBURG FAMILY MEDICINE CENTER
- Practice address
- 475 N Highway 25 W Ste 100
Williamsburg, KY 40769-1576 - Phone
- (606) 549-2933
- NPI assigned
- Jan 30, 2007
- Organization subpart
- No
Authorized official
- Name
- Christy Timmins
- Title
- CPC
- Phone
- (423) 784-0269
Owners & managing parties with NPI records 3
-
Gregory Charles Wilkens, M.D.
-
Darryl John Wilkens, M.D.
-
Todd Henry Wilkens, M.D.
Practitioners 11
-
Sheila Denise Lambdin, APRN
-
Linda C. Hale, ARNP
-
Taylor R Perkins, PMHNP-BC
-
Aaron Dewayne Petrey, PA-C
-
Darryl John Wilkens, M.D.
-
Heather Mae Demaree, P.A.C.
-
Robert Lee Penn, MD
-
Jimmye Shannon Perkins, M.D.
-
Todd Henry Wilkens, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 18D0323826 | Williamsburg Family Medicine Center | Certificate of waiver | Apr 19, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in KY
Rural health clinic certification: CCN 183832
- Legal name
- WILLIAMSBURG FAMILY MEDICINE CENTER
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 12, 1996
- Last certification
- Oct 2, 2017
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Incorporated
- May 7, 1999 in KY
- Enrollment address
- 475 Hwy 25 WN
Suite 100
Williamsburg, KY 40769-1576
All disclosed owners & managing parties 4
| Name | Role | Since | Share |
|---|---|---|---|
| Darryl John Wilkens |
5% Or Greater Direct Ownership Interest |
Dec 27, 2021 | 33% |
| W-2 Managing Employee | Dec 27, 2021 | ||
| Stephen Boone |
Corporate Officer |
Jan 1, 2013 | |
| W-2 Managing Employee |
Dec 27, 2021 | ||
| Todd H. Wilkens |
5% Or Greater Direct Ownership Interest | Dec 21, 2021 | 33% |
| Gregory C. Wilkens |
5% Or Greater Direct Ownership Interest | Dec 21, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040311000399 | KY | Part a Provider - Rural Health Clinic | 2365331188 | Practice locations: Williamsburg, KY |
| O20041108001285 | KY | Part B Supplier - Clinic/Group Practice | 2365331188 |
Receives reassigned benefits from 8 practitioners Practice locations: Williamsburg, KY |
National Provider Directory
Locations
131 Hospital Ln
Jellico, TN 37762
Phone (423) 784-7269
Interoperability endpoints
- https://api.platform.athenahealth.com/24026/brand/1/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 900065 | KY | Yes |
Addresses
Primary practice location
475 N Highway 25 W Ste 100
Williamsburg, KY 40769-1576
Mailing address
PO Box 247
Jellico, TN 37762-0247
Phone (423) 784-0269
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 35000553 | Medicaid | KY |
Other providers in Williamsburg, KY
- Whitley County Health Dept.
- Whitley County Health Dept.
- Whitley Pharmacy, Inc.
- David Bernard Williams
- Williamsburg Chiropractic Corp
- Williamsburg Family Practice Clinic
- Williamsburg Family Practice Clinic, Inc.
- Williamsburg Independent School District
- Williamsburg Nursing Home, Inc.
- Williamsburg Pharmacy
All providers in Williamsburg, KY · Rural Health Clinic/Center in Kentucky
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 15, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.