NPIMap

Organization Active NPI

Advanced Family Medical Clinic Mount Vernon

Doing business as Advanced Family Medical Clinic

  • Rural Health Clinic/Center
  • Somerset, KY
National Provider Identifier
1578090403
Registry record updated Jan 16, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON
Doing business as
Advanced Family Medical Clinic
Practice address
79 Sarahs LN
Somerset, KY 42503-2789
Phone
(606) 687-9017
Fax
(606) 655-1030
NPI assigned
May 23, 2017
Last updated
Jan 16, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 16, 2026

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

Authorized official

Name
Dr. Khursheed Akram Siddiqui, MDNPI 1881634368
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)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X 28741 KY
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

79 Sarahs LN
Somerset, KY 42503-2789

Mailing address

PO Box 2369
Danville, KY 40423-2369
Phone (606) 392-2060

Other names 1

  • Advanced Family Medical Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170620000449 KY Part A Provider - Rural Health Clinic 2062780810 Practice locations: Somerset, KY
O20171026003512 KY Part B Supplier - Clinic/Group Practice 2062780810 Receives reassigned benefits from 14 practitioners
Practice locations: Somerset, KY

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1578090403. Details of each certification follow.

Rural health clinic certification: CCN 188971

Legal name
ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON
Doing business as
ADVANCED FAMILY MEDICAL CLINIC
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
LLCProprietary
Enrollment address
79 Sarahs LN
Somerset, KY 42503-2789

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
18D2132041Advanced Family Medical Clinic Mt Vernon79 Sarahs Lane, Somerset, KY 42503Certificate of waiverJun 11, 2027

National Provider Directory

National Provider Directory

Locations

50 Lovell Ct
Mount Vernon, KY 40456
Phone (606) 386-1917

79 Sarahs Ln
Somerset, KY 42503
Phone (606) 386-1917

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.

NameRoleSinceShare
Khursheed Akram Siddiqui Individual 5% Or Greater Direct Ownership Interest May 15, 2017 50%
Corporate OfficerPresident May 15, 2017
W-2 Managing EmployeePresident May 15, 2017
Operational/Managerial ControlPresident May 15, 2017
Sheba M Siddiqui Individual 5% Or Greater Direct Ownership Interest Jun 17, 2017 50%
Corporate OfficerSecretary May 15, 2017
Operational/Managerial ControlSecretary 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.

  • Khursheed A Siddiqui, MD
    • Pain Medicine Physician
    • Danville, KY
    • NPI 1881634368

    5% Or Greater Direct Ownership Interest, Corporate Officer, Operational/Managerial Control, W-2 Managing Employee

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1495497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1768521600000",
    "number": "1578090403",
    "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": "606-392-2060",
            "fax_number": "606-655-1030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "79 SARAHS LN",
            "city": "SOMERSET",
            "state": "KY",
            "postal_code": "425032789",
            "telephone_number": "606-687-9017",
            "fax_number": "606-655-1030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-23",
        "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": "193400000X MULTIPLE SINGLE 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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Family Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Somerset, KY

Sources for this page

Verify at the official NPI Registry.