Active NPI
Advanced Family Medical Clinic Mount Vernon
- Rural Health Clinic/Center
- Somerset, KY
National Provider Identifier
1578090403
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- ADVANCED FAMILY MEDICAL CLINIC MOUNT VERNON
- Practice address
- 79 Sarahs LN
Somerset, KY 42503-2789 - Phone
- (606) 687-9017
- Fax
- (606) 655-1030
- NPI assigned
- May 23, 2017
- Organization subpart
- No
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 18
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 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 |
|---|---|---|---|
| 18D2132041 | Advanced Family Medical Clinic Mt Vernon | Certificate of waiver | Jun 11, 2027 |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in KY
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
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
- LLC
- Enrollment address
- 79 Sarahs LN
Somerset, KY 42503-2789
All disclosed owners & managing parties 2
Medicare enrollment filesAs 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 |
National Provider Directory
National Provider DirectoryLocations
50 Lovell Ct
Mount Vernon, KY 40456
Phone (606) 386-1917
79 Sarahs Ln
Somerset, KY 42503
Phone (606) 386-1917
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
79 Sarahs LN
Somerset, KY 42503-2789
Mailing address
PO Box 2369
Danville, KY 40423-2369
Phone (606) 392-2060
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7100503150 | Medicaid | KY |
Other names 1
- Advanced Family Medical Clinic
NPI Registry JSON
{
"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": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "7100503150",
"state": "KY"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Advanced Family Medical Clinic",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Somerset, 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.