1528484037 NPI number — SPECIALTY PHYSICIAN ASSISTANT,LLC

Table of content: (NPI 1528484037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528484037 NPI number — SPECIALTY PHYSICIAN ASSISTANT,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY PHYSICIAN ASSISTANT,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RUSSELL FORK WALK-IN CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528484037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41502-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-754-7100
Provider Business Mailing Address Fax Number:
606-754-0770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17401 KY HIGHWAY 80 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41522-8226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-754-7100
Provider Business Practice Location Address Fax Number:
606-754-0770
Provider Enumeration Date:
03/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BURCHFIELD
Authorized Official First Name:
NICHOL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
606-422-4764

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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