Provider Demographics
NPI:1477557882
Name:PHYSICIANS CLINICAL LABORATORY
Entity Type:Organization
Organization Name:PHYSICIANS CLINICAL LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-688-1225
Mailing Address - Street 1:815 E PARRISH AVE
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3222
Mailing Address - Country:US
Mailing Address - Phone:270-688-1200
Mailing Address - Fax:270-688-1204
Practice Address - Street 1:815 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3222
Practice Address - Country:US
Practice Address - Phone:270-688-1200
Practice Address - Fax:270-688-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200254291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000229569OtherBCBS PROVIDER ID
KY000000229569OtherBCBS PROVIDER ID