Provider Demographics
NPI:1700150109
Name:EGAN CLINIC PSC
Entity Type:Organization
Organization Name:EGAN CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:O
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-228-7530
Mailing Address - Street 1:12945 W HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9107
Mailing Address - Country:US
Mailing Address - Phone:502-228-7530
Mailing Address - Fax:502-228-7533
Practice Address - Street 1:12945 W HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9107
Practice Address - Country:US
Practice Address - Phone:502-228-7530
Practice Address - Fax:502-228-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39726207R00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100195370Medicaid
KY7100195370Medicaid