Unknown Individual – Family Medicine Physician, NPI 1083631550

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Benton, Kentucky. specializing in Family Medicine Physician. They hold a License No. 20835 (KY). The NPI Number for Unknown Individual is 1083631550

Main info

Organization

Inactive

47 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1083631550

Phone

(270) 527-8601

Address

83 WELLNESS WAY

Deactivation Date

19 April 2022

Doctor Profile

Medical School Name

UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE

Secondary Phone

2705270045

Graduation Year

1979 (47 years ago)

PAC ID

7911066618

Group Practice PAC ID

1153488648

Professional Enrollment ID

I20081111000092

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

83 WELLNESS WAY
BENTON, KY 420257156
Phone: (270) 527-8601
Fax: (270) 527-9615
Type: Location
Boom Box Buns, 1324, Main Street, Main Street Business District, Over-the-Rhine, Cincinnati, Hamilton County, Ohio, 45202, United States
CINCINNATI, OH 452636961
Phone: (513) 981-5130
Fax: (513) 981-5015
Type: Mailing

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 42025)

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Provider's Procedures

Unknown Individual performs procedures in Family Medicine Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
FAMILY MEDICINE	KY	90670	Pneumococcal vaccine for injection into muscle	61	61

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 1153488648View full group profile

Name	Specialty	State
GARY BODNARCHUK (M.D.)	-	OH
DR. PATRICK BASU (M.D.)	-	NY
PAMELA DIANE GREEN (APRN)	-	KY
MS. PEGGY JO HALE (APRN)	Nurse Practitioner	OH
KIMBERLY J LOVELL (APRN)	-	KY
DAVID JOHN MAUTERER (MD)	-	KY
MARISSA LAYNE STEWART-JAYNES (MD)	Family Practice	OH
LINDA M DALL (NP)	Nurse Practitioner	OH
MR. ROBERT AARON HAYDEN (PA-C)	-	OH
BONNIE K. GRACE (A.P.R.N.)	-	OH