Provider Demographics
NPI:1609931658
Name:ASHLAND CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:ASHLAND CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-329-0204
Mailing Address - Street 1:700 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2620
Mailing Address - Country:US
Mailing Address - Phone:606-329-0204
Mailing Address - Fax:606-324-7770
Practice Address - Street 1:700 13TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2620
Practice Address - Country:US
Practice Address - Phone:606-329-0204
Practice Address - Fax:606-324-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65917544Medicaid
KY65917544Medicaid