Provider Demographics
NPI:1588626717
Name:JOSEPH A CLAN JR PSC
Entity Type:Organization
Organization Name:JOSEPH A CLAN JR PSC
Other - Org Name:TENDERCARE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CLAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:502-966-3918
Mailing Address - Street 1:5211 COMMERCE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2183
Mailing Address - Country:US
Mailing Address - Phone:502-966-3918
Mailing Address - Fax:502-969-3665
Practice Address - Street 1:5211 COMMERCE CROSSING DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-2183
Practice Address - Country:US
Practice Address - Phone:502-966-3918
Practice Address - Fax:502-969-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22815208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64228158Medicaid
KY0267201Medicare ID - Type Unspecified
KYC72160Medicare UPIN