Provider Demographics
NPI:1003842501
Name:ERTEL MEDICINE & PEDIATRICS, PSC
Entity Type:Organization
Organization Name:ERTEL MEDICINE & PEDIATRICS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-744-0067
Mailing Address - Street 1:1520 BOONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-8816
Mailing Address - Country:US
Mailing Address - Phone:859-744-0067
Mailing Address - Fax:859-744-0042
Practice Address - Street 1:1520 BOONESBORO RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-8816
Practice Address - Country:US
Practice Address - Phone:859-744-0067
Practice Address - Fax:859-744-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35650207R00000X
208000000X
KY900132261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH24943Medicare UPIN
KY183892Medicare Oscar/Certification