Provider Demographics
NPI:1205616265
Name:SOUTHFORK MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:SOUTHFORK MEDICAL CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-376-7212
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-0490
Mailing Address - Country:US
Mailing Address - Phone:606-376-7211
Mailing Address - Fax:
Practice Address - Street 1:57 MEDICAL LANE
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653
Practice Address - Country:US
Practice Address - Phone:606-376-7211
Practice Address - Fax:606-376-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center