Provider Demographics
NPI:1154500296
Name:ESTILL MEDICAL CLINIC, PSC
Entity Type:Organization
Organization Name:ESTILL MEDICAL CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ISFORT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-723-2167
Mailing Address - Street 1:275 COURT ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1077
Mailing Address - Country:US
Mailing Address - Phone:606-723-2167
Mailing Address - Fax:606-723-2112
Practice Address - Street 1:275 COURT ST
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1077
Practice Address - Country:US
Practice Address - Phone:606-723-2167
Practice Address - Fax:606-723-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000507512OtherANTHEM
KY64142649Medicaid
KY64142649Medicaid
KY1118201Medicare PIN
KY11182Medicare PIN